The Non-Negotiables: What to Look for in a Claims Workflow Solution

The pressure on insurance operations has never been higher. As customer expectations grow and the industry shifts towards data-driven, tech-first models, claims teams find themselves at the heart of transformation. But here’s the catch, many are still trying to force-fit legacy workflows into modern requirements.

If you’re at the stage of building requirements for a new claims solution, now’s the time to take a step back – not just to digitise what you have, but to reimagine what should be.

1. Map the Moments That Matter
Not all steps in the claims process are equal. While FNOL (First Notice of Loss) is your obvious starting point, moments like triage, adjudication, and payment decisioning are where customer experience and operational efficiency are truly won or lost.

Ask:
• Where are the current delays?
• Which steps require the most human intervention?
• Which steps introduce the highest risk of leakage or error?
Pro Tip: Don’t just digitise every step. Instead, automate the predictable, flag the exceptions, and build in escalation paths for high-touch cases.

2. Define the Data You Need at Each Step
One of the biggest pain points in traditional claims workflows is that data comes in late, incomplete, or in silos. For example, if fraud indicators or policy limits aren’t visible during triage, adjusters are left second-guessing – or worse, missing critical red flags.

Build a “data wishlist” aligned to each step:
• Triage: Policy data, customer history, fraud scores
• Adjudication: Third-party reports, internal guidelines, image/video uploads
• Payment: Bank details, tax info, audit trails

Tip: Look for systems that allow API-based (Application Programming Interface) integrations to bring this data in dynamically – not as static fields, but as living, up-to-date intelligence.

3. Prioritise Configurability Over Customisation
Many insurers fall into the trap of over-customising their claims systems, leading to ballooning implementation timelines and expensive change requests down the line.

A modern claims platform should let you:
• Build rules and workflows without hardcoding
• Configure authority limits and approval flows dynamically
• Create smart dashboards by role, region, or claim type

Think of it this way: Customisation locks you in. Configurability lets you evolve.

4. Don’t Forget the Human Layer
Automation is powerful. But claims decisions often require judgment, empathy, and nuance – especially in complex or high-stakes scenarios.

That’s why your ideal workflow shouldn’t just enable machines – it should empower humans:
• Built-in collaboration tools (no more back-and-forth emails)
• Integrated notes and audit trails
• Role-based access and accountability checkpoints

Bottom line: Great workflows don’t replace humans. They make them sharper, faster, and more confident.

5. Bake in Compliance and Audit Readiness
No one enjoys preparing for an audit or regulatory review. But when compliance is an afterthought, the consequences are expensive – and reputationally damaging.

Your workflow should:
• Auto-log every user action
• Store versions of decisions and documents
• Trigger alerts for breaches in timelines or SLAs (Service-Level Agreements)
Bonus: A system built for compliance makes regulatory reporting easier, not harder.

6. Build for Scale, Not Just Speed
It’s tempting to optimise workflows for immediate gains – faster settlements, quicker cycle times. But if you don’t design for scale, today’s solution will become tomorrow’s bottleneck.

Look for systems that:
• Can handle multi-line, multi-region operations
• Support AI/ML modules that learn from historical data
• Are cloud-native, not just cloud-hosted (yes, there’s a difference!)
Future-ready isn’t just a buzzword. It’s a non-negotiable.

Think Workflow First, Platform Second
Before you go platform shopping, invest time in deeply understanding your ideal-state workflow. The right technology partner should fit into your vision – not the other way around.

At this stage, what you need is clarity. Clarity on what matters, what slows you down, and what’s truly possible. Because when you get the workflow right, the rest follows.

Let’s talk workflow
If you’re exploring a claims workflow platform built for today’s challenges and tomorrow’s scale, our team would love to show you how we’re helping forward-thinking insurers reimagine their claims journey with our proprietary product – Mozart ClaimsPro.
Reach out to us for a quick discovery session or a no-obligation walkthrough.