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Claims Reimagined:
A UX Prescription for a Pain-Free Claim Processing Experience

Transforming the claims experience from complex and outdated to seamless and efficient. The legacy mainframe system created usability roadblocks, slowing down claim processing and limiting productivity. By introducing a modern, user-friendly product experience, we streamlined workflows and boosted efficiency—resulting in a 25% reduction in average claim processing time.

Overview

Solution

Design a unified review experience that blends manual and automated workflows into a single system—reducing tool switching, streamlining interventions, and providing contextual guidance and performance insights. By supporting phased automation, this solution meets business needs in the current transition state while laying the foundation for a fully automated future.

My Role & Team

As lead UX designer and researcher, I managed a junior UI designer and collaborated with product owners, stakeholders, a project manager, and technical leads.

Tools Used

Figma, Miro, Mural, User Brain Testing Platform

Current Product Ecosystem

The legacy experience required users to navigate multiple screens. We discovered they were organizing their many open windows by color and location on their dual monitor setups to manage resources, review claims, and follow process instructions. This made it difficult for users to quickly find relevant information, leading to inefficiencies and increased cognitive load. The fragmented interface forced claim processors to switch between screens, tabs and windows frequently, slowing down their workflow and increasing the likelihood of errors. The lack of an intuitive structure meant users had to rely on prior knowledge or documentation to complete tasks, reducing overall productivity and claim review accuracy.

Challenges

Outdated Interfaces
Processors rely on an old system (CPA) and separate Word documents for claim processing, creating inefficiencies. A unified tool is needed to integrate manual and automated review steps.

Many Processing Resources
Due to complex review instructions and multiple branching processes, processors often manage 10+ open windows per claim, making it difficult to track resources.

Extreme Variation
Claim review process instructions vary by length and complexity based on the type of claim and review needed making standardization challenging.

Limited Effectiveness
Two tools were developed previously to improve the review process, but testing showed they didn’t enhance the experience or scale effectively.

Lack of Real-time Support
Processors need better post-training guidance and resources to handle complex cases efficiently.

High Technical Barrier
Users with limited technical skills struggle navigating the various databases required for claim processing.

Disorganized Training Materials
Resources are fragmented across sectors (e.g., hospital vs. physician) and stored in different locations, making it difficult to access the right information when needed.

Project Goals

Enhance

Allow users to focus on review quality by streamlining manual intervention and automating applicable process. Providing users relevant context and on demand direction in moments of potential continued learning.

Align

Bring all tasks into a single application to reduce unnecessary switching between tools. Integrate performance tracking within the new system so processors can work efficiently while monitoring their progress.

Support

Consolidate and streamline SME and processor experiences with an integrated workflow allowing in exception tracking and review auditing within the same experience.

Product Discovery & Design Approach

A range of UX design and research methods were utilized to understand user needs and validate the strategy for an intuitive claims processing experience. These methods included journey mapping the experience, conducting user interviews, empathy mapping and job to be done workshops, and completing a competitive analysis to gather insights.

Empathy Maps and Jobs to Be Done

Empathy mapping and Jobs-to-Be-Done (JTBD) workshops were pivotal in understanding the challenges faced by claims processors. These activities highlighted that processors often juggle multiple windows and rely on outdated tools, leading to cognitive overload and inefficiencies. The empathy maps revealed emotional stressors, such as frustration with scattered knowledge sources and the pressure to maintain accuracy amidst complex workflows.

The JTBD sessions uncovered that processors aim to efficiently complete claim reviews while minimizing errors and seeking real-time support. These insights informed the design of a unified interface that integrates automated and manual review steps, consolidates resources, and provides contextual guidance. By aligning the tool with the processors’ core objectives and emotional needs, the solution enhances focus, reduces errors, and supports continuous learning within the claims processing workflow.

Multi User Journey Map

The journey map exposed workflow gaps across coders, auditors, and team leads—highlighting fragmented systems, rework from unclear documentation, and limited visibility into claim progress. These insights drove the need for a centralized, guided platform to streamline handoffs, reduce errors, and support each role more effectively.

User Personas

We identified three main personas: Processors, Subject Matter Experts and Instructional Designers/Trainers. We ran UX empathy map and job to be done sessions with our users and conducted user interviews based on a list of predefined JTBD from our stakeholders. We used insight from these sessions to create a primary persona for our processor and supporting personas for SME’s and Trainers.

Design Sprints

Using the Google Ventures Design Sprint method, we applied affinity mapping to identify key jobs to be done, which informed our design sprints. These sprints generated ideal user workflows, technical considerations, and a high-fidelity prototype for the targeted experience.

Proof of Concept

Prototype Walkthrough: Guided Multi-Review Workflow

This prototype demonstrates how coders are supported when a claim is editing to multiple reviews—beginning with a 672 review, which has been automated. The system alerts the user that the claim is also editing to additional reviews, including 5080 and 479 (also automated), as well as a 426 review, which remains manual. The 426 was selected for this proof of concept due to its high volume, accounting for 47% of coder work queue reviews. The prototype introduces a hybrid workflow that guides the user through automated reviews before returning them to manually complete the 426, ensuring accuracy across the full claim lifecycle.

Key capabilities in this new workflow include AI-powered automation, consolidated views of claim details and review instructions, and the ability to view completed automated reviews—which may contain important information relevant to manual ones. Keeping all review data visible, regardless of automation status, supports QA, reduces errors, and empowers coders to make informed decisions as they navigate complex, multi-review scenarios.

User Testing

Key Findings

We conducted task based and pattern preference user testing with over 30 participants to validate and iterate the new claim processing experience.

Reduce Collaboration Overhead
Provide a multi-user experience in a single application by consolidating and streamlining SME and processor experiences with an integrated workflow. Enabling SMEs and Processors to work in the same environment would eliminate significant overhead for both roles

Self-Monitor Performance
Eliminate context-switching relating to activity type and performance progress by including integrations with Omega to auto-switch the processor’s activity type, and with iDash to include performance data into the processor’s UI so that they can keep working efficiently while also monitoring progress toward goals in real time

Eliminate Context Switching & Window Overload
Include data, description, guidance, reference materials, tools and controls in the same UI in the moment of need

Awareness in Real-Time
Compose, edit, announce, publish and control production release of PI/SOP updates in the same application where Processors use the instructions