REVOLUTIONIZING CLAIM ADJUDICATION: DESIGNING INTELLIGENT, PANDEMIC-RESILIENT CONTACT CENTER SYSTEMS IN HEALTHCARE TECHNOLOGY

Abstract

This paper presents original research into the transformation of healthcare claim adjudication systems through the adoption of intelligent, pandemic-resilient contact center systems. Traditional systems, as highlighted during the COVID-19 pandemic, were found inadequate—relying on manual workflows, siloed data management, and rigid architectures that failed to scale under unprecedented claim volumes. To address these challenges, this study introduces the Intelligent Claims Optimization Framework (ICOF), a structured methodology for designing systems that detect, validate, and process claims efficiently while maintaining a human-centric approach. By leveraging predictive analytics, real-time data processing, and scalable cloud infrastructure, this research demonstrates how intelligent systems significantly enhance accuracy, reduce errors, and expedite claim resolution, while preserving a human-centric approach for critical cases. The study further explores the scalability of these systems during crises, their seamless integration with healthcare platforms like electronic health records (EHRs), and their ability to maintain operational continuity in remote work scenarios. Through case studies and comparative analyses, the research quantifies the advantages of intelligent systems over traditional models, showcasing their potential for improving efficiency and stakeholder satisfaction. This paper concludes by advocating for the proactive adoption of cutting-edge healthcare technologies to build resilience and sustainability, ensuring readiness for future challenges in the healthcare landscape.