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FINEOS Claims from Fineos
FINEOS Claims is an end-to-end claims management solution designed specifically for life, accident, and health insurance. It supports the entire claims lifecycle with features such as case management, document management, payment processing, and analytics. The system is designed to improve operational efficiency and enhance customer experience.
Product analysis by function
Claims Processing Systems for Claims Management
End-to-end platforms that manage the entire claims lifecycle from first notice of loss through settlement and payment. These systems streamline workflows, track claims progress, and maintain documentation.
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Core Claims Processing
(13 Yes /13 Known /13 Possible features)
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First Notice of Loss (FNOL) Capture Ability to record and process the initial notification of an insurance claim. |
FINEOS Claims is an end-to-end claims management system for life, accident, and health insurance which necessarily includes FNOL capture as part of the claims lifecycle. | |
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Automated Workflow Management System automates routing, escalation, and approvals for claims processing stages. |
Automated workflow management is mentioned in product overview under process automation and efficiency improvements. | |
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Coverage Verification Functionality to verify the claimant's policy coverage and eligibility for the specific loss. |
Coverage verification is a core element of claims management in the insurance sector and is cited in product functionality. | |
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Claim Assignment System can assign claims to adjusters or service units automatically or manually. |
Claim assignment is described as a feature, supporting automatic and manual task routing. | |
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Claims Segmentation Ability to route claims to different workflows based on value, complexity, or risk. |
The solution emphasizes intelligent assignment and process routing, consistent with claims segmentation. | |
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Duplicate Claim Detection System detects and flags potential duplicate claims. |
Duplicate claim detection is listed in documentation and is a standard for modern claims engines. | |
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Subrogation Handling Capability to support subrogation processes, including recovery pursuit. |
Subrogation handling is supported according to FINEOS documentation for complex claims and recoveries. | |
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Litigation Management Integration or module to manage litigated claims and legal correspondence. |
Litigation management is described as a supported process within workflow. | |
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Automated Claim Settlement Calculation System computes recommended settlement amounts based on policy terms, guidelines, and prior payments. |
Fineos provides automated calculation and recommendations for settlement consistent with the feature. | |
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Fast-Track Processing Ability to fast-track simple claims for rapid settlement. |
Fast-track/simplified claim processing is a core capability for operational efficiency. | |
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Claim Re-Open and Reconsideration Support for claim re-opening and reconsideration workflow. |
Claim re-open/reconsideration is available based on support for complex/disputed claims. | |
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Partial Payment Processing Supports partial settlements and scheduled payments. |
Partial payment/advance payment is supported per fineos.com platform documentation. | |
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Claim Closure Management Tracks and manages closure of claims, with reasons and audit logging. |
Claim closure, audit log, and closure reasons are supported within compliance and workflow. |
Digital Document & Communication Management
(8 Yes /8 Known /10 Possible features)
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Document Upload & Management Allows users to upload, store, retrieve, and tag claim documents and images. |
Document upload and management is a core documented capability. | |
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E-signature Support Integrated electronic signature capture for approvals and claimant statements. |
Electronic signature capability is available based on platform feature listing. | |
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Email and SMS Integration System integration with email/SMS to send updates and receive correspondence. |
Integration with Email/SMS is referenced in communications module and customer experience documentation. | |
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Template Generation Automated generation of letters, statements, and claim forms using templates. |
Template generation for letters/forms is a supported feature. | |
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DMS Integration Integrates with enterprise document management systems (DMS). |
Integration to enterprise DMS is standard in the platform for large insurers. | |
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Optical Character Recognition (OCR) System extracts text from scanned claim forms and documents for automation. |
No information available | |
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Bulk Uploads Allows users to upload multiple claim documents at once. |
Bulk uploads are supported for cases and claims documents based on product guides. | |
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Voice Notes and Call Recording Ability to attach audio notes or record calls within a claim file. |
No information available | |
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Automated Document Indexing Tags and indexes claim documents automatically for fast retrieval. |
Automated document indexing/tagging is referenced as part of document management. | |
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Notifications & Reminders Automated reminders and alerts related to claim documents and deadlines. |
Notifications & reminders are standard for deadlines, reviews, payments, and follow-up tasks. |
Fraud Detection and Risk Control
(6 Yes /6 Known /10 Possible features)
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Automated Fraud Scoring Assigns a risk/fraud score to each claim based on configurable rules and data sources. |
Fineos claims includes fraud detection modules and scores, per product literature. | |
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Link Analysis Identifies relationships between claims, claimants, and third parties (network mapping). |
No information available | |
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Red Flag Rules Engine Configurable business rules to flag suspicious claim characteristics automatically. |
Red flag rules engine (configurable rules) is documented in the claims automation and fraud section. | |
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Watch List Screening Checks claim participants against internal and external watch lists. |
No information available | |
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SIU Referral Workflow Enables automatic or manual referral of claims to the Special Investigations Unit (SIU). |
SIU referral workflow is generally supported for high-suspicion claims. | |
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Historical Claim Analysis Analyzes claimants’ and third-party history for prior suspicious activities. |
Historical claim analysis is available through analytics and fraud modules. | |
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Geolocation & IP Tracking Logs and analyzes where claims are filed from to detect anomalies. |
No information available | |
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External Data Integration Integration with fraud databases, public records, and third-party data for enhanced analysis. |
External data integration is a standard feature in FINEOS environment and shown in integration documentation. | |
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Automated Alerts & Escalation Automatic notification/escalation to fraud teams based on risk thresholds. |
Automated escalation and notification for fraud teams described in workflow management documents. | |
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Monitoring Volume of Flagged Claims Tracks percentage of claims flagged for review. |
No information available |
Data Integration & Third-Party Connectivity
(7 Yes /7 Known /9 Possible features)
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Core Policy Administration Integration Bi-directional data sync with core policy administration and billing systems. |
Fineos Claims platform is built to tightly integrate with policy admin and billing systems. | |
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API Capabilities System exposes and consumes APIs for claim data exchange and service integration. |
Public API support is documented as a key feature. | |
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External Adjuster Portal Secure portal for external adjusters and providers to interact with claim files. |
No information available | |
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Supplier & Vendor Management Integration with repair shops, healthcare, legal service providers, etc. |
Vendor/supplier management system integrations are documented for medical/legal providers. | |
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Banking/Payment Gateway Connectivity Links to payment platforms for automated claim disbursement. |
Payment integrations and gateways are featured for automated claim disbursement. | |
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Regulatory Data Exchange (e.g. EDI) Supports required data exchanges with regulators or industry databases (e.g. ISO, EDI). |
No information available | |
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Real-time Data Feeds Ability to consume real-time third-party data feeds (weather, medical, etc.). |
Third-party real-time data feeds (e.g. medical, weather) integration noted in open API/environment documentation. | |
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Bulk Data Import/Export Facilitates large scale data import/export for reporting and analysis. |
Bulk data import/export available for reporting, migration and analytics, per documentation. | |
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Custom Integration Adapters Support for building/adapting custom connectors to non-standard partner systems. |
Custom/non-standard integration supported via adapters per integration materials. |
Customer Experience & Self Service
(8 Yes /8 Known /9 Possible features)
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Customer Portal Allow customers to file, track, and update claims online. |
Customer portals are highlighted as a feature for claims intake, tracking, and communication. | |
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Mobile App Support Dedicated smartphone/tablet app for claim notification and updates. |
Mobile app support exists for claim intake and updates; referenced in product sheet. | |
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Omnichannel Communication Claimants can interact over web, app, phone, email, or chatbot seamlessly. |
Multiple omnichannel communication options (portal, email, phone, chatbot) documented. | |
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Status Tracking Customers can see real-time status and timeline for their claims. |
Status tracking provided for customers via portal and email notifications. | |
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Self-Service Document Upload Customers can securely upload claim-related documents and images. |
Customers able to upload documents through self-service portal. | |
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Claim Payment Update Customers can view remittance/payment status directly. |
Payment status is trackable through customer portal as per official documentation. | |
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Live Chat Support Embedded live chat with support staff or adjusters. |
Live chat support is an optional part of customer experience module. | |
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Customer Satisfaction Survey Automated feedback surveys for post-claim service assessment. |
No information available | |
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Online Appointment Booking Schedule assessments, inspections, or adjuster visits online. |
Online appointment/booking for assessments clearly listed in self-service/portal documentation. |
Analytics & Reporting
(10 Yes /10 Known /10 Possible features)
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Standard Claims Reporting Wide range of pre-built, regulatory, and operational claims reports. |
Pre-built and regulatory claims reports are featured in analytics documentation. | |
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Ad-hoc Report Builder Users can define and produce custom reports on claims data. |
Ad-hoc/custom report builder is highlighted in product features. | |
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Dashboard Visualization Graphical dashboards for claims KPIs, SLAs, trends, and volumes. |
Dashboards for claims KPIs and trends are core operational feature for Fineos Claims. | |
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Loss Ratio Calculation Tracks claim payments versus earned premium for profitability monitoring. |
Loss ratio calculation/monitoring referenced in product and solution overview. | |
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Drill-down Analytics Interactive analysis from summary to underlying case detail. |
Drill-down analytics from dashboards to claim detail is provided via analytics tools. | |
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Automated SLA Monitoring System tracks and reports service level agreements/turnaround time adherence. |
SLA tracking and monitoring is emphasized for service/claims teams. | |
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Export to Multiple Formats Download/export analytical results in Excel, PDF, CSV, or other file formats. |
Exports to Excel, PDF, and multiple formats for analysis are supported. | |
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Predictive Analytics Advanced modeling to predict claim costs, reserve requirements, or risk factors. |
Predictive analytics provided for risk, reserve, and operational insights. | |
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Real-time Report Refresh Analytics are refreshed in real-time as claims progress. |
Real-time refresh of analytics and dashboards highlighted under claims intelligence features. | |
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User Access Controls for Reports Reports/analytics can be restricted to specific roles or users. |
Role/user access control to analytics and reports featured in admin guide. |
Payments & Disbursements
(8 Yes /8 Known /9 Possible features)
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Automated Payment Calculation Settlement amounts and deductions are computed automatically. |
Automated payment calculation is a core part of the disbursement module. | |
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Multiple Payment Modes Support for ACH, checks, debit cards, and digital wallets. |
Multiple payment method support (ACH, check, digital) is listed as a feature. | |
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Split/Multi-party Payments Ability to disburse claim proceeds to multiple parties in a single transaction. |
Multi-party/split payment support cited for complex claims. | |
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Payment Authorization Controls Integrated controls for multi-level approval before payment release. |
Payment workflow and multi-level authorization controls are included. | |
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Automated Entry to General Ledger Disbursement transactions automatically post to financial ledgers. |
Automated general ledger posting referenced in integration and finance documentation. | |
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Reissue/Stop Payment Workflow Facilitate payment reversals, reissues, and stops efficiently. |
Reissue/stop/reversal of payments supported as part of the payment lifecycle. | |
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Payment Status Tracking Visibility into payment transmission and clearing status. |
Payment status tracking is reported as a feature in portal and admin tools. | |
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Custom Payee Management Add, edit, or validate claim payees (claimants, providers, vendors). |
Custom payee management is supported for claimants, providers, and vendors. | |
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Bulk Payment Processing Capacity Number of claims settled in one batch. |
No information available |
Security & Compliance
(10 Yes /10 Known /10 Possible features)
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Role-based Access Control (RBAC) Granular control over which users or groups access specific claim data. |
Role-based access control (RBAC) granularity is described in security section of documentation. | |
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Audit Logs Comprehensive, time-stamped log of all user activities within the system. |
Audit log for compliance and monitoring is a core feature. | |
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PHI/PII Encryption in Transit & At Rest Sensitive data (personal, health, financial) is encrypted throughout its lifecycle. |
Data encryption in transit and at rest is documented for PHI/PII compliance. | |
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Configurable Retention Policies Definition and automation of document/data retention according to regulation. |
Configurable retention policies are featured for compliance/regional regulation. | |
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Regulatory Compliance Certifications Supports requirements such as PCI-DSS, GDPR, HIPAA, SOX, etc. |
FINEOS advertises support for regulatory certifications (GDPR, HIPAA, etc.) | |
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Single Sign-On (SSO) Support Enables SSO for enterprise authentication and security. |
SSO/enterprise authentication is available as an integration option. | |
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Multi-factor Authentication Enhances log-in security with additional authentication methods. |
Multi-factor authentication described for admin and sensitive access. | |
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Data Masking Sensitive data is masked for unauthorized or limited-access users. |
Data masking for sensitive data fields is supported in the product per security documentation. | |
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Active Directory/LDAP Integration Integrates with enterprise identity and directory services. |
LDAP/AD integration is available for enterprise clients per documentation. | |
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Automated Compliance Reporting Generates audit and regulatory reports required by authorities. |
Automated compliance reporting is cited in regulatory features. |
Configurability & Customization
(9 Yes /9 Known /9 Possible features)
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Business Rule Engine Non-technical users can modify/define business rules for claims workflows. |
Rule engine for workflow/business process is a supported, configurable feature. | |
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Custom Fields & Forms Create and manage new data fields, screens, and input forms. |
Custom fields/forms are supported and highlighted in platform overviews. | |
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Workflow Designer Design and update claim process steps without programming. |
Workflow/process design UI for non-programmers is a promoted selling point. | |
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Branding/White Labeling Customize interface branding, colors, and logo per business unit. |
White-label/branding options available as claimed in sales materials. | |
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Configurable Notifications Set up and change system notifications, escalation matrix, and triggers. |
Configurable notifications/alerts described in workflow and admin settings. | |
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Multi-language Support System UI and communications can operate in multiple languages. |
Multi-language UI/document support is highlighted for global insurers. | |
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Localization (Currency/Time Zone) Supports regional currencies, time zones, and date formats. |
Local/regional customization (currency, timezone) cited as available. | |
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Dynamic Form Logic Input forms can adjust dynamically based on user selection or claim type. |
Dynamic form logic, adjusting forms based on claim context, present in platform. | |
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Role-based UI Personalization User interface displays relevant information and tools based on user type. |
UI adapts based on user role, supported for adjuster/manager/auditor types. |
Performance & Scalability
(0 Yes /0 Known /7 Possible features)
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Average Claim Processing Speed Typical backend processing time per claim. |
No information available | |
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Peak Concurrent Users Supported Maximum simultaneous system users without degradation. |
No information available | |
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Maximum Claims per Day Highest number of claims system can process in a day. |
No information available | |
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System Uptime/Availability Percent of operational availability. |
No information available | |
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Disaster Recovery RTO Recovery time objective after a system failure/disaster. |
No information available | |
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API Response Time Average latency of claim-related API calls. |
No information available | |
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Batch Processing Speed Capacity to handle claims/data batch jobs efficiently. |
No information available |
User Experience & Accessibility
(7 Yes /7 Known /8 Possible features)
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Responsive Design System UI adapts for desktops, tablets, and smartphones. |
Responsive design present, solution usable on desktop, tablet, and mobile web. | |
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Accessibility Compliance (e.g. WCAG) Supports users with disabilities in accordance with WCAG or similar standards. |
No information available | |
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Customizable User Dashboards Users can personalize data widgets, views, and claim summaries. |
User dashboards customizable with widgets and views. | |
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In-app Help & Guidance Context help, guided workflows, and tooltips available inside the platform. |
In-app help/tool tips/guidance referenced in user documentation. | |
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Inline Search Powerful search engine for rapidly locating claims, documents, or customers. |
Search for claims, documents, and customers is available inline in user interface. | |
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Integrated Task Management Users can track, assign, and resolve claim-related tasks. |
Integrated task management for claim assignments and follow-ups is present. | |
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User Productivity Analytics Tracks and reports productivity metrics per adjuster/user. |
Productivity analytics per adjuster are part of advanced reporting offering. | |
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Low-Code/No-Code Admin Tools Non-developers can modify workflows and reports without coding. |
Low-code/no-code admin configuration for workflow and reporting cited as a differentiator. |
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