A US-based healthcare insurer, serving 3.4 million members across 18 states, was looking to transition from a high-growth start-up to a scale-driven value creator. With plans covering individuals, families, small businesses and Medicare Advantage members, the insurer had a complex web of operations to keep everything moving, from provider onboarding and maintenance, network operations, claim holds and inquiries, clinical reviews to day-to-day workforce coordination.
The ticketing system supporting this was built on Jira/Atlassian tools, which began to show cracks as operations expanded with a growth in members and providers in the network, as well as increasing regulatory oversight.
The more the teams relied on Jira, the more its limitations showed. This was not an issue that tracking dashboards could solve. To scale as a value creator, the insurer needed a mission-critical case management platform.
Moment of Realization
As cycle times jumped from their baseline to noticeably longer durations; backlog counts peaked to levels no one was comfortable with; the number of teams touching a single case was higher than ever.
Compliance and privacy became a concern. HIPAA requirements were tightening, and the current system struggled to provide the level of control and traceability regulators increasingly expected. Preparing for audits consumed too many hours per cycle. The client needed an operational transformation, not just generic issue tracking.
It turned to Persistent as its transformation partner.
Designing a New Foundation
Persistent worked with network operations staff, provider lifecycle coordinators, clinical reviewers and workforce managers to trace how a request entered the system, which teams touched it, where it stalled and what information was needed at each step.
The ask was clear: a platform that serves as a single source of truth, designed specifically for complex healthcare workflows, underpinned by role-based access control for PHI compliance and embedded automation for audit trails.
Persistent built this foundation on Appian, a low-code/no-code platform that is well-suited for regulated, process-intensive operations. Appian enables case types to be clearly defined, priority-based routing rules, role-based access and permission model, audit trails and integrates seamlessly with existing systems, eliminating duplicate work and manual data entry.
The transformation was not a single “big bang” launch. It unfolded in carefully managed phases, each balancing speed with readiness for control.
Phase 1 – Discovery & Control Design: Over the initial few weeks, Persistent confirmed high-volume workflows, mapped existing handoffs, delays and paint points:
- Confirmed which workflows and volumes would move first
- Mapped existing handoffs, delays and pain point
- Defined a role taxonomy and PHI boundaries: who should see what and under which conditions
- Documented exactly what needed to be logged and reported for audits
- Aligned on success metrics: cycle time, touches per case, backlog levels, SLA adherence
Phase 2 – Pilot Build: With the pilot well underway, Appian was configured around real operational needs:
- Case types, queues and routing logic tailored to high-volume work
- Role-based access embedded from day one
- Priority integrations: identity/SSO, core claims and provider systems, document repositories
Phase 3 – Scale-Out Rollout: Once confidence in the model grew, the platform expanded:
- Additional workflows, such as provider management, claims inquiries/holds, clinical review and workforce management, were brought onto Appian
- Reusable components emerged: shared data models, task templates, exception-handling patterns
- Operational dashboards were introduced, offering leaders real-time insight into throughput, aging, SLA risk and workload distribution
Phase 4 – Stabilization & Operate: As the platform became the operational backbone, Persistent helped the client stand up a sustainable operating model:
- Runbooks and monitoring practices ensured reliability
- Incident response processes and release governance were defined
- Admins and business super-users were trained through targeted sessions and job aids so they could own and evolve the platform going forward
This wasn’t just a tool implementation; it was the establishment of a new operational foundation.
Resilient Operational Backbone
The client transformed its network operations from a patchwork of tickets and manual workarounds into a centralized, compliant and scalable digital platform.
As volumes grew, the platform kept pace and helped the client with:
- Scalability: From handling a more modest request load to managing more than 6,500 claim holds and queries per day. The system processes 750,000 requests in the first six months of the rollout.
- Efficiency: Manual triaging and reassignment time per case dropped with automation and smarter routing.
- Compliance: Role-based access, complete case histories and policy-aligned data handling made it far easier to demonstrate HIPAA and privacy adherence. Time spent assembling evidence for audit cycles also dropped significantly.
- Resource Utilization: Same-day assignment rates climbed as automatic task assignment and workload balancing ensured that incoming work was quickly matched to available capacity.
Today, as regulatory expectations continue to evolve and healthcare markets grow more complex, the client’s operations are no longer constrained by the limits of simple ticketing. Instead, it stands on a foundation designed for the realities of regulated healthcare, supported by a foundation ready to support the next wave of growth and innovation.
