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This Triager will work ALL escalated Member Issues and Complaints.
What is the Expedited Triager Role?
100
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In this section you will find all of the Cases assigned to you.
What is My Work List?
100
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For all Non A&G Issues I will go to this section of the Left-Hand Panel.
What is Non A&G Work Basket?
100
In this section of PRIME I can view all notes taken during the Compilation process.
What is the Case Screen in the Footer section for Notes/Global notes?
100
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The Case Coordinator sends Cases to this Role for determination and review when applicable.
What is the Lead Supervisor and or Manager Role?
200
This Role deals with the Admin Determination and Approval of Complaints.
What is the Lead, Supervisor and Manager Role?
200
On the Left Hand Panel you will use this tab and section to search for Members, Providers, Authorizations and Claims to assist your final outcome.
What is the Global Search section?
200
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Under my Work List I will use this tab to refresh periodically through out Work Flow.
What is Refresh List tab?
200
In this section of PRIME I can view the Name of member, timeline for Work, status of case, dates received and any IDs associated to this case.
What is the Header in PRIME?
200
All communication cases begin in this primary role.
What is Triager?
300
This Role can pull the Member Issues from the Non A&G issues Work Basket, and can access Complaint cases created from Non A&G Member Issues and or Communications created from those complaints.
What is the Non A&G Triager?
300
In this section of the Left-Hand Panel you can view your most recent Member Issues, Appeals and Communication Cases.
What is RECENT?
300
Under My Work List I will go to this tab to pull the next assigned Member Issue.
What is the Next Assignment tab?
300
During Triaging I can find these tabs within this screen:
Member Issue, Issue Details, Contactor, Case History, Eligibility Details, Routing, Documents
What is the Case Screen in PRIME?
300
This Role will view all complaint cases and any associated communication case to assist with a determination.
What is a Case Coordinator?
400
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This user has the ability to search and view cases in the system but does not have access to any of the reports.
What is Audit Role?
400
As a Triager you will always be able to create a Member issue from this section of the Left-Hand Panel.
What is Manual Member Issue/Create Member Issue?
400
Within this section of the Left-Hand Panel I will able to view all assigned Member Issues to myself.
What is Work Basket; Member Issues?
400
Under the RECENT section of the Left-Hand Panel when reviewing an existing issue you will have these (3) tabs for review.
What is Overview, Information & Audit?
These are the tabs that house the information to be reviewed such as OVERVIEW case content, AUDIT- global notes per issue, and INFORMATION- all assigned communication cases for that issue.
400
Complaint Case can be sent to different departments based on the outcome of the case. When it is finalized this is called___________.
What is Determination also know as Clinical Review?
500
In this Role the user can see reports from PEGA and any applicable system for Reports.
What is Report User?
500
From this section of the Left-Hand Panel you can search for any Member Issue, Communication or Complaint Case.
What is Search Case/Member Case Search?
500
On the Left-Hand Panel I can view all the items within my Work List from this section.
What is PRIME OPS "Jeanine Dallas" (1)?
500
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This screen shows us a view of the following: Left Panel, Roles, Worklist, Workbasket, Create Manual Issue, Case Search, Global Search, and Recent cases.
What is the DASH Board?
500
_____________________ is required on ALL Appeal types and Quality of Care Grievances.