UC-428
Member Appeals and Grievance Casework
Reads each appeal and its history, assembles the decision file against the original criterion, and drafts the reply inside the clock.
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The Challenge
Appeals and grievances carry statutory turnaround clocks and a late response is a sanction, not just a service failure. Case files get rebuilt by hand from the claim, the authorisation and the call recordings.
How It Works
- Reads the appeal letter, the original denial rationale, claims, authorisations and calls.
- Rebuilds the decision timeline, checks the criterion applied and flags an incomplete file.
- Puts the assembled file and drafted reply to the appeals nurse with the clock time left on it.
What It Removes
- Rebuilding the case file from four separate systems
- Manual clock tracking across expedited and standard
- Retyping the original denial rationale into the reply
Input Data RequirementsAppeal and grievance correspondence, original denial rationale, claims and authorisation records, call notes, regulatory turnaround rules
Output FormatAssembled case file with a decision timeline, drafted member response letter, clock and ageing dashboard by case type and by market
“The clock runs whether or not we have found the recording, and building the file is most of the work”