Case Study: Molina Healthcare achieves faster appeals and grievances resolution with Pegasystems Pega

Molina Healthcare transforms appeals and grievances

Molina Healthcare, a Fortune 200 health insurer serving more than 4.5 million members, needed a more scalable and sustainable way to manage appeals and grievances as it outgrew its homegrown applications. Its legacy process was inefficient, hard to standardize across health plans, and created manual work, duplicate denials, and other operational issues. Molina turned to Pegasystems, using Pega and guidance from Cognizant to modernize the process.

Pegasystems implemented Pega’s Appeals and Grievances solution on the Pega Platform, leveraging case management, workflow automation, and real-time analytics to streamline end-to-end operations and integrate with core systems. The results included $3 million in annual savings, a 30% reduction in case resolution time, and 60,000 hours saved per year from automated outbound correspondence, while also reducing new plan onboarding from months to weeks.

Molina Healthcare

Balaji Subramaniayan

Principal Engineer