Streamlining Health Insurance Operations
A New Integrated Core Management System with Complete Process Automation
ABOUT THE CLIENT
SETS is a non-profit, solidarity-based Health Insurance Institution that has been providing benefits to healthcare workers and their families for over 40 years. Created through a partnership between employers and employees, SETS is a self-managed organization that aims to offer complementary insurance coverage.
ABOUT THE PROJECT
Industry
HEALTH INSURANCE
Business Model
FIXED PRICE
Client Location
URUGUAY
Tech Stack
Project Duration
2 YEARS
Team Size
6
HIGHLIGHTS
NEW INTEGRATED AUTOMATED CORE MANAGEMENT SYSTEM
This comprehensive two-year development project successfully replaced SETS' core operational system with an integrated, automated solution that now manages all aspects of its healthcare insurance operations.
SEAMLESS TRANSITION: FROM LEGACY TO INNOVATION
The new system has been successfully operating in production since July 2024. The legacy platform was fully decommissioned following a methodical one-month parallel operation period.
OPERATIONAL TRANSFORMATION: AUTOMATION DRIVING EFFICIENCY
The solution delivered substantial operational improvements through comprehensive automation of core processes, including payment calculations, reimbursement management, and application authorizations– capabilities that transformed SETS' previous manual processes into streamlined, efficient operations. The solution implements a comprehensive calculation engine that processes multiple variables including coverage levels, service types, provider agreements, and member-specific conditions. This enables the automation of indemnity calculations and payment reconciliation.
PARTNERING FOR SUCCESS
The development process was characterized by exemplary client collaboration, including regular remote demonstrations, strategic meetings with the directorate, and comprehensive user acceptance testing.
CLIENT GOALS
SETS was interested in acquiring a bespoke software solution to replace their core system. This new digital platform needed to achieve:
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Streamlining of all management activities within the organization, tailored to its specific policies.
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Improved operational efficiency and response time through integrated automated payment calculations.
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Enhanced agile communication between the institution and its members.
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Easy access for beneficiaries to manage and track their applications.
THE STRATEGY
After analyzing SETS's needs and goals, our business analyst elaborated a detailed roadmap, based on which the optimal architecture, feature set and implementation technology stack for the software was defined. This enabled the estimation of the necessary project resources and the strategic planning of the deliverables, budget, and timeline.
A full development team was assigned to the project consisting of two back-end, two front-end, and one full-stack developer, as well as a functional QA tester. The team included a mix of senior, mid-level, and junior developers to optimize costs while maintaining high-quality standards for the project.
DEMO meetings were scheduled with the client to review the increments. This collaborative inspection enabled early feedback, creating a shared understanding of the product and its goals, verifying that it meets the client's expectations.
After reaching the halfway point of the project, user acceptance testing was conducted by the client to verify that the solution met its goals and delivered the expected results.
Prior to deploying the solution in the production environment, Globe carried out the migration of the client's business data to the new management platform.
The replacement of SETS' core system was a complex challenge that required meticulous planning and execution. The transition strategy centered on maintaining uninterrupted service delivery while implementing the new system. This was achieved through a carefully orchestrated parallel operation period, ensuring no disruption to member services processing.
The parallel operation phase also enabled thorough validation of critical functions such as payment processing, benefit calculations, and member data management before the final cutover.
TECHNOLOGY STACK
Design:
FIGMA
Frontend:
REACT
Backend:
JAVA
Database:
MYSQL
SCM:
GIT & GITHUB
SERVICES OFFERED
Custom Software development
Quality Assurance (QA)
Architecture solution
Data migration
THE OUTCOMES
The cutting-edge integrated management system is a tailored, configurable, and easy-to-use digital solution that integrates all departments within the institution, improving internal organization and boosting productivity.
With this unique IT tool, SETS is now enabled to manage all aspects related to healthcare insurance, from operational management (including recording basic member information, health insurance history and global/monthly credit limits, authorization of prescriptions and reimbursements) to commercial and accounting operations (as supplemental health insurance payments, billing, financial information and more).
The platform has allowed the synchronization of data across previously disconnected systems, creating a cohesive information flow that eliminated manual processes, bringing transparency and enabling real-time access to critical information.
The automation of healthcare insurance workflows represented a significant technical achievement in this project. The system implements sophisticated business rules that handle complex scenarios such as multi-tier benefit structures, varying coverage levels and provider-specific arrangements. The automation engine processes applications through multiple validation stages, applying policy rules, coverage limits, and member-specific conditions in real-time.
The system also empowers the affiliates to manage their own accounts, including submitting requests and tracking their status.
Some of its key technical features include:
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A seamless and intuitive user interface with a standardized layout, allowing for a consistent and optimized navigation experience across all sections.
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Full transactional reliability, guaranteeing that every process within a transaction is securely stored in a database and executed without errors.
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Integration with advanced database engines, ensuring robust security, efficient data management, and customizable access controls and permission settings.
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A modular architecture design that enables the activation or deactivation of features based on the organization's specific needs.
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Built-in tools for exporting data, simplifying reporting and external analysis.
The digital platform was released in July 2024. Since then, new functions and modules have been incorporated, always in pursuit of maximum efficiency and members benefits.