Despite increased access to claims management technology, claims denials are still on the rise in 2024. Contributing factors include growing healthcare costs, stricter payer reimbursement policies, and claims processing errors. Providers continue to see claims being denied in greater numbers. As per a report, in 2022, 42% of respondents said denials are increasing. The number jumped to 77% in 2024. Similarly, the time it takes to be reimbursed is increasing, per 67% of respondents. That number was 51% in 2022. These inefficiencies clog revenue cycles, frustrate providers, and erode patient trust. As the demand for seamless, compliant, and patient-centric systems grows, the pressure to overhaul outdated claims adjudication processes has never been greater.
The challenge is formidable. Older, often batch-oriented and manual, check-based legacy systems cannot cope with the volume and complexity of contemporary health care data. They are slow, error-prone, and not well-suited to handle real-time requirements. Federal compliance adds another layer of sophistication, as does integration with external payer systems. The vast majority of organizations recognize that they must transform, but the way ahead is complicated, calling for technical acumen as well as a strategic vision in marrying systems to business and community objectives.
Recognizing the need for specialized Business Process Management expertise, the organization engaged Haritha Murari, a Senior System Architect with a Master’s degree in Computer Science and more than 12 years of progressive experience in IT application development. Certified as a Pega Senior System Architect and Pega Decisioning Consultant, she has delivered enterprise-scale solutions with Pega PRPC across the healthcare, insurance, and finance sectors.
In this assignment, she was engaged to drive design and implement a scalable claims-eligibility-verification system, an area noted for its complexity and operational risk. Her leadership improved processing accuracy and reduced cycle time, establishing new benchmarks for efficiency and service quality within the organization and for the federal-employee population it serves.
The stakes were high. The organization processed millions of claims annually, but inefficiencies in eligibility checks led to delays, rejections, and strained provider relationships. Legacy systems relied on batch processing, creating bottlenecks that slowed payouts and increased manual workloads. She saw the bigger picture: a system that could validate claims in real time, reduce errors, and free up resources for patient care.
“It’s not just about fixing a process,” she said during a team briefing. “It’s about building trust, making sure providers and patients know the system works for them.”
Her flagship project was a real-time eligibility verification processor, a game-changer for claims adjudication. She designed and implemented a system that integrated with external payer systems using EDI X12 270/271 transactions, automating eligibility checks and routing decisions. By leveraging Pega’s advanced case types, decision tables, and data pages, she created a modular, scalable architecture that ensured compliance with federal standards. The results were striking: claim rejections dropped by 35%, eligibility check times fell by 40%, and first-pass resolution rates rose by over 20%. These gains didn’t just save costs—they enabled providers to focus on care rather than paperwork.
She didn’t stop there. Recognizing the power of data-driven decisions, she integrated predictive models and limited generative AI to enhance customer interactions. Adaptive analytics optimized outbound communications, while AI-generated content streamlined self-service tools, boosting member response rates by 15%. This meant fewer calls to customer service, faster resolutions, and happier patients. By reducing administrative friction, her work empowered care coordinators to prioritize patient outcomes, strengthening community trust in the system.
Her approach was as strategic as it was technical. She designed reusable rule sets and case structures that became templates for other departments, from billing to provider credentialing. Her deployment automation, using queue processors and job schedulers, slashed downtime and improved system reliability across environments. She also built comprehensive debugging protocols, leveraging tools like Pega’s Clipboard and Tracer to catch issues early. These innovations weren’t just fixes, they were a foundation for long-term scalability. Her eligibility processor was featured in internal case studies, and its design principles were adopted across multiple business units.
Beyond her technical contributions, she showed remarkable leadership. She mentored junior developers, sharing best practices for Pega development and fostering a culture of collaboration. Her detailed documentation and training sessions ensured teams could maintain and build on her work. She also took on additional responsibilities, such as aligning business requirements with technical solutions and presenting prototypes to executives. Her efforts earned her accolades from IT and business leadership, cementing her reputation as a trusted innovator.
Haritha Murari’s impact extended beyond the organization. She published peer-reviewed research in IEEE conferences and international journals, exploring healthcare IT solutions and influencing industry standards. As a reviewer for prestigious awards like Brandon Hall and Globee, she helped recognize transformative technologies. She also judged global IT competitions, mentoring aspiring professionals and inspiring innovation. These contributions positioned her as a thought leader, amplifying the reach of her work.
“Seeing my designs spark ideas for others is what drives me,” she shared at a conference. “It’s about creating systems that last and lift everyone up.”
The numbers tell a powerful story. Her system eliminated manual checks for thousands of claims daily, saving operational costs and reducing provider-payer reconciliation delays. By standardizing workflows, it cuts reporting cycles from weeks to days, enabling faster financial and clinical decisions. These efficiencies freed up resources for community health programs, benefiting federal employees and retirees who depend on reliable coverage. Globally, her approach offers a model for reducing administrative waste, allowing healthcare systems to prioritize care over bureaucracy.
What if this transformation hadn’t happened? Delays in eligibility checks would have persisted, driving up costs and denials. Providers would have faced ongoing disputes, and patients would have endured billing frustrations. Non-compliance risks could have triggered regulatory penalties, undermining trust. In the worst case, errors in claims processing could have delayed critical care, a risk no healthcare system can take lightly.
By stepping in, she didn’t just solve a technical problem, she removed a systemic barrier. Her reusable frameworks and performance-tuning techniques became blueprints for other enterprise systems. Her focus on modularity and compliance ensured the system could adapt to future needs, from AI-driven diagnostics to telehealth expansion. This forward-thinking approach is why her work resonates beyond one organization, setting benchmarks for the industry.
Haritha Murari’s story is a reminder that progress often comes from those who see both the code and the stakes. Her contributions, technical, strategic, and human, show what’s possible when expertise meets purpose. In a world where healthcare systems are stretched thin, her work is a beacon of how thoughtful innovation can save time, money, and trust, one claim at a time.
