Insurance Plans


Project Background

A major health insurance company serving nearly 50 million members with over 24,000 providers and annual revenues of over $2 billion. 400 CSRs in two locations linked as a virtual center. Company regularly ranks among best in class in customer service and employee satisfaction
Business Challenge

Advice sought by management on right number and sizing of call centers. Need to increase scheduling efficiency without negatively affecting agent morale. Required independent assessment of overall call center performance.
Project Approach
  • Two person project team led a six week assessment of the two call center locations
  • Analyzed call center data and metrics
  • Conducted interviews of key personnel from senior management to frontline employees to gain perspective on current operations
  • Assessed technology, quality program, organizational structure, and processes for scheduling and performance assessment
  • Observed agents handling voice and email contacts, and observed supervisors and managers in action
Business Benefits The assessment yielded several key recommendations which included:
  • Changing Organization Structure
  • Revising Quality Program and Coordinating Quality Process between Supervisors and Monitors
  • Redesigning and Replacing Call Center Technology to Better Support Call Routing and Improve Disaster Recovery Capabilities
  • Redesigning Performance Measures and Integrating into Schedule Bid Process
  • Redesigning Performance Reporting System to Reduce Technology Risk

Project Background

A major provider of health insurance – member of a national association of health care plans. The company delivers individual and group health plans and third party administration services to large clients
Business Challenge

Sales and enrollment process was overly complex, didn’t meet different needs of different customer segments
Project Approach Two person project team worked with cross-functional team of client staff, departmental management, and executive management over six months to:
  • Determine client expectations and appropriate metrics for the process
  • Map core activities and develop “as-is” process maps
  • Review process disconnects and design new “to-be” process maps
  • Develop system requirements necessary to support re-designed process
  • Create new roles, position descriptions, and organization charts for affected departments
  • Develop implementation plan and business case for required investment
Business Benefits
  • Client implemented recommendations in Marketing, Underwriting, and Customer Service departments to improve service and reduce cycle time
  • Customer Service recommendations reduced abandon rates from 12% to 2% and improved service levels without hiring staff
  • Process analysis and business case justified necessary staffing increases and new positions in Marketing and Sales
  • System requirements incorporated in RFP for new system by client’s IT department

Project Background

Major health care provider known for providing outstanding customer service and operational excellence
Business Challenge
  • Growth in volume led to performance of the claim process becoming unstable and unpredictable as real-time workflow reporting and process information were not available to process owners or participants
  • Growth and acquisitions were pushing current process beyond its capability to meet member and provider SLA’s
  • Claim Processor Supervisors and Sr. Claim Processors were spending too much time collecting, integrating and defining workflow data and as a result they were not spending time coaching and developing employees
Project Approach Two person project team worked with cross-functional team of client staff, departmental management, IT, supervisors, process subject matter experts and executive management over 5 weeks to:
  • Benchmark “As Is” claim process metric/report capability (inventory current metrics and criteria for claim process)
  • Design “To Be” claim process metric/report (Dashboard and Scorecard) requirements
  • Identify gaps between “As Is” and “To Be” metric report states
  • Provide Level-1 “As Is” process map to identify process Key Performance Indicators (KPI’s) and Performance Indicators (PI’s)
  • Establish metric/report standards for claim process that align with corporate values and strategies (Operational Excellence & Growth)
  • Develop Level-1 “To Be” process map utilizing BPM best practices
  • Provide Findings/Recommendations/Industry Best Practices
Business Benefits
  • Identified metrics that provide real-time visibility and process control
  • Recommended Implementation of BPM solution that automatically prioritizes and routes work
  • Brief review identified over $1,000,000 in cost savings, risk reductions, and process improvements
  • Projected return on investment based on action plans of 500%, payback in less than six months

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