AI-assisted Member Enrollment Optimization for Fortune 25 MCO
Overview
Fortune 25 managed care organization offering affordable and high-quality products to more than 1 in 15 individuals across the nation, including Medicaid and Medicare members (including Medicare Prescription Drug Plans) and individuals and families served by the Health Insurance Marketplace and the TRICARE program.
The member enrollment process is critical in ensuring seamless healthcare access for customers. However, the increasing complexity and enrollment velocity pose significant challenges, leading to application processing delays, documentation errors, and customer dissatisfaction. These inefficiencies impact customer experience and contribute to lower star ratings of health plans, high drop rates, and increased operational costs. Addressing these challenges is vital for improving customer retention and ensuring business continuity.
The enrollment process presented several operational hurdles that impacted efficiency and customer satisfaction, including:
System limitations: Multiple sources of enrollment intake resulting in mass auto upload failure in the customer platform and increased manual efforts. Data distributed across multiple sources (e.g., systems, spreadsheets, templates, Workflows, and PDFs).
Delays in Application Processing: Complex workflows and high volumes resulting in slower turnaround times, affecting coverage initiation for enrolled members.
Errors in Documentation: Mismanagement of documents leading to discrepancies, increasing rework and compliance risks. A complicated electronic load process and immediate ramp-up was required.
Customer Dissatisfaction: Inefficiencies in enrollment directly impacted customer experience, increasing complaints and drop rates.
Business and Financial Impact: Lower star ratings and high dropout rates affecting business growth and profitability.
Ineffective Workload Management: Poor prioritization leading to missed TAT (Turnaround Time), additional rework, and increased operational costs.
Solution.
Coforge implemented a structured digital-first approach focusing on workflow optimization, data-driven decision-making along with right skilling and right shoring to address these challenges.
Team Onboarding
Built a team of highly experienced, plug-and-play subject matter experts to streamline current processes.
Ensured that resources were well-versed in industry best practices to enhance operational efficiency.
Insights & MIS
Developed a well-defined Management Information System (MIS) for efficient inventory and priority management.
Implemented Workforce Distribution and Tracking System (WDTS) to enhance monitoring and productivity.
Developed omnichannel for multiple intake sources.
Workforce Optimization
Cross-trained resources to enable dynamic load balancing during peak seasons, ensuring TAT adherence.
Optimized resource allocation to reduce dependency on specific individuals and enhance flexibility.
Defined and implemented Quality Framework with a robust transaction monitoring framework
Established a flex/scale model to manage the Annual Enrollment Period (AEP)
Training & Development
Introduced robust training and certification programs to ensure “faster-to-production” readiness.
Ensured a stable operational environment with continuous learning and skill enhancement initiatives.
The Impact.
The implementation of these strategic measures resulted in significant operational improvements:
50% Reduction in Turnaround Time within six months, enhancing application processing speed.
100% Quality Scores achieved since the initiative's inception, improving accuracy and compliance.
20% Productivity enhancement through quality-focused processes that significantly reduce rework requirements.
15% reduction in manual activities, elevating member experience and providing best-in-class accuracy in output.
Custom-built Terms Monitor WFM solution enhances operational visibility and business intelligence, providing transparency into core processes.
Comprehensive Cross-Skilling ensures workforce flexibility and improved adaptability to workload variations.
Accelerated Hiring-to-Production Timeline, reducing it to just 6 weeks, ensuring quicker onboarding and productivity.
Coforge’s member enrollment workflow optimization solution successfully transformed client’s enrollment process by enhancing efficiency and scalability, reducing costs, and improving customer satisfaction. The structured approach streamlined operations and contributed to overall business growth and sustainability.
