Digital. Dynamic. Dependable.
Enhancing CAHPS Scores and Star Ratings through Faster, Member-centric Resolution
Intake, categorize, investigate, and resolve complaints with smarter routing and dynamic case documentation. Deliver compliant, member-centric complaint handling that improves CAHPS scores and Star ratings.
“Newgen’s Grievances and Complaints Management Solution has substantially improved our workflow efficiency. The solution streamlined case capture and helped us ensure effective adherence to regulatory compliance. Furthermore, the AI-driven capabilities have been instrumental in resolving complaints faster, resulting in higher member satisfaction and maximized operational performance.”
Vice President, Grievances and Appeals, A Leading Health Plan
Built for Payers. Designed for Members
Leverage our Complaints, Appeals, & Grievances Suite to build trust with a member-first approach.
Efficient Case Management
Detect and flag duplicates to prevent fraud and speed up medical and pharmacy resolutions. Automate case allocation to optimize bandwidth. Manage escalations, prioritize cases, and extend case timelines as necessary. Ensure robust integration with document management capabilities to streamline content-centric workflows, improve accuracy, and fast-track claims and reviews.
Unified Information Capture and Processing
Consolidate data capture from multiple sources for efficiency. Fetch eligibility details of members and providers in one place. Leverage GenAI to extract critical data, classify records, and generate instant summaries for informed decision-making.
Automated Communications, Audit Documentation, and Packet Generation
Generate automated correspondences, including acknowledgment and resolution letters, to ensure adherence to regulatory mandates. Compile case summaries with relevant clinical, medication, formulary, and benefit data and artifacts. Create downloadable case packets for internal/external audits and CMS compliance. Customize reports to meet CMS requirements and gain insightful analytics for informed decision-making.
360-degree Case Visibility, Decision Support, and Integration
Access a comprehensive dashboard to manage cases and get periodic status reports and updates. Leverage AI/ML algorithms to support decision-making and enhance efficiency. Integrate pharmacist and medical director clinical/MD reviews into the process for accurate case assessment. Ensure robust integrations with external portals for smooth data exchange. Ensure data accuracy and compliance through intelligent validation mechanisms.
Timely and Impactful Grievance Management
Streamline operations with AI-driven capabilities that enhance clinical intelligence, predict inventory trends, and optimize document identification. Leverage intelligent mailroom capability to ensure each grievance is accurately identified, categorized, and routed to the correct process, thereby enabling timely, informed decisions.
Improved Quality of Care Grievances
Enhance grievance operations with built-in QOC workflow, designed to simplify and accelerate the resolution of quality of care complaints. From real-time intake to automated clinical routing and investigation to resolution tracking, manage every step intelligently for speed and accuracy. Stay compliant, automate correspondence, and ensure audit-ready documentatio. Leverage smart category mapping, one click medical record retrieval through EHR connector and provider trend analytics to drive better outcomes.
Efficient Case Management
Detect and flag duplicates to prevent fraud and speed up medical and pharmacy resolutions. Automate case allocation to optimize bandwidth. Manage escalations, prioritize cases, and extend case timelines as necessary. Ensure robust integration with document management capabilities to streamline content-centric workflows, improve accuracy, and fast-track claims and reviews.
Unified Information Capture and Processing
Consolidate data capture from multiple sources for efficiency. Fetch eligibility details of members and providers in one place. Leverage GenAI to extract critical data, classify records, and generate instant summaries for informed decision-making.
Automated Communications, Audit Documentation, and Packet Generation
Generate automated correspondences, including acknowledgment and resolution letters, to ensure adherence to regulatory mandates. Compile case summaries with relevant clinical, medication, formulary, and benefit data and artifacts. Create downloadable case packets for internal/external audits and CMS compliance. Customize reports to meet CMS requirements and gain insightful analytics for informed decision-making.
360-degree Case Visibility, Decision Support, and Integration
Access a comprehensive dashboard to manage cases and get periodic status reports and updates. Leverage AI/ML algorithms to support decision-making and enhance efficiency. Integrate pharmacist and medical director clinical/MD reviews into the process for accurate case assessment. Ensure robust integrations with external portals for smooth data exchange. Ensure data accuracy and compliance through intelligent validation mechanisms.
Timely and Impactful Grievance Management
Streamline operations with AI-driven capabilities that enhance clinical intelligence, predict inventory trends, and optimize document identification. Leverage intelligent mailroom capability to ensure each grievance is accurately identified, categorized, and routed to the correct process, thereby enabling timely, informed decisions.
Improved Quality of Care Grievances
Enhance grievance operations with built-in QOC workflow, designed to simplify and accelerate the resolution of quality of care complaints. From real-time intake to automated clinical routing and investigation to resolution tracking, manage every step intelligently for speed and accuracy. Stay compliant, automate correspondence, and ensure audit-ready documentatio. Leverage smart category mapping, one click medical record retrieval through EHR connector and provider trend analytics to drive better outcomes.
Newgen’s CAG Solution for Fast-tracked NCQA Accreditation
Fast-track your accreditation process while minimizing manual efforts, ensuring audit-readiness, and improving member satisfaction.
Learn What NewgenONE Grievances and Complaints Solution Can Do for You
Centralized Case Management
Capture and create cases from diverse channels, including web portals, mailrooms, and faxes. Ingest data from CRMs and external systems in a hassle-free manner. Manage all types of complaint, including quality of care, quality of service, enrollment, and customer service, and formulary complaints, ensuring structured resolutions. Use AI to summarize complaints and analyze sentiment, ensuring no complaints go unnoticed.
Intelligent Mailroom, Data Enrichment, and Case Assignment
Ensure robust integration with advanced document processing capabilities to manage incoming documents effectively. Fetch eligibility, claims, and authorization and drug details from core systems. Delegate cases based on the skills and expertise of coordinators. Prevent fraudulent activities with duplicate detection, and easily identify closed or similar cases to add additional information for quicker resolution.
Collaboration, Communication, and Audit readiness
Foster cross-team collaboration, enabling nurses, doctors, pharmacists, and operational admins to review and redirect cases on a unified platform. Capture case research automatically for audits. Create detailed case packets for audits and external reviews, ensuring accountability and compliance. Generate compliant letters without any manual intervention.
Advanced Search, Reporting, and Oversight
Employ quick and advanced search capabilities to retrieve cases based on the type and specific criteria throughout the lifecycle. Access detailed dashboards for 360-degree visibility into member or provider cases. Generate operational, compliance, and business intelligence reports. Tailor business reports to meet specific requirements or integrate custom modules.
Integrated Quality Assurance and Performance Evaluation
Implement sampling algorithms to evaluate coordinator efficiency and work accuracy. Ensure thorough case reviews with detailed checklists. Assign performance scores for coordinators and enable bi-directional communication between auditors and researchers for addressing changes. Provide custom and distinct views for intake workers, research coordinators, QA auditors, supervisors, and managers.
Comprehensive Case History and Issue Management
Capture complete case histories, including decisions, notes, and exceptions, for future reference. Manage multiple issues within a case grid, categorized by the National Committee of Quality Assurance (NCQA) and Health Plan Management System (HPMS), including pharmacy access and network grievance, for efficient segregation and resolutions.
Centralized Case Management
Capture and create cases from diverse channels, including web portals, mailrooms, and faxes. Ingest data from CRMs and external systems in a hassle-free manner. Manage all types of complaint, including quality of care, quality of service, enrollment, and customer service, and formulary complaints, ensuring structured resolutions. Use AI to summarize complaints and analyze sentiment, ensuring no complaints go unnoticed.
Intelligent Mailroom, Data Enrichment, and Case Assignment
Ensure robust integration with advanced document processing capabilities to manage incoming documents effectively. Fetch eligibility, claims, and authorization and drug details from core systems. Delegate cases based on the skills and expertise of coordinators. Prevent fraudulent activities with duplicate detection, and easily identify closed or similar cases to add additional information for quicker resolution.
Collaboration, Communication, and Audit readiness
Foster cross-team collaboration, enabling nurses, doctors, pharmacists, and operational admins to review and redirect cases on a unified platform. Capture case research automatically for audits. Create detailed case packets for audits and external reviews, ensuring accountability and compliance. Generate compliant letters without any manual intervention.
Advanced Search, Reporting, and Oversight
Employ quick and advanced search capabilities to retrieve cases based on the type and specific criteria throughout the lifecycle. Access detailed dashboards for 360-degree visibility into member or provider cases. Generate operational, compliance, and business intelligence reports. Tailor business reports to meet specific requirements or integrate custom modules.
Integrated Quality Assurance and Performance Evaluation
Implement sampling algorithms to evaluate coordinator efficiency and work accuracy. Ensure thorough case reviews with detailed checklists. Assign performance scores for coordinators and enable bi-directional communication between auditors and researchers for addressing changes. Provide custom and distinct views for intake workers, research coordinators, QA auditors, supervisors, and managers.
Comprehensive Case History and Issue Management
Capture complete case histories, including decisions, notes, and exceptions, for future reference. Manage multiple issues within a case grid, categorized by the National Committee of Quality Assurance (NCQA) and Health Plan Management System (HPMS), including pharmacy access and network grievance, for efficient segregation and resolutions.
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