• Service performance and quality issues: SLA slippage, low first-call resolution, high adjustment rates and inconsistent adherence to critical-to-quality (CTQ) measures
• Compliance and financial exposure: Unmet compliance requirements and penalties paid to plan sponsors due to missed performance guarantees, contributing to higher operational costs and increased medical loss ratio (MLR) impact
• Limited orchestration and visibility: Absence of an enterprise Business Process Management (BPM) platform led to manual work allocation via spreadsheets across disparate data sources and limited reporting
• Inconsistent quality governance: Manual, inconsistent quality sampling and reporting reduced insights for proactive, data-driven action planning
• Knowledge and SOP sprawl: Standard Operating Procedures (SOPs) scattered across SharePoint without effective governance or learning pathways impacted average handle time (AHT), hold times and compliance outcomes
• Automation technical debt: Homegrown automations were prone to frequent failures, increasing operational risk and maintenance burden
• Paper-heavy enrollment workflows: High volumes of paper-based enrollments (especially during open enrollment) drove longer handling times and avoidable errors due to manual processing

These constraints limited the plan’s ability to improve operational efficiency, strengthen compliance and deliver consistent experiences for members, brokers and providers.

• Establish unified work orchestration and gain real-time visibility across operations
• Reduce manual effort and rework through AI and scaled Robotic Process Automation (RPA) automation, with agentic automation (initiatives in progress)
• Enable faster and intelligent document processing
• Strengthen quality, auditability and SLA compliance
• Shorten onboarding cycles and improve time to proficiency for operations teams
• Enhance member, broker and provider experience through faster, more consistent resolution

• Smart orchestration and governance: Deployed highly configurable BPM as a centralized orchestration layer that supports intelligent, automated skill-based work allocation for each business area, rule-based sampling and auditing
• Digital command center and insights: Provided on-demand, real-time reporting and actionable insights so that all business leaders could engage in proactive workload balancing, forecasting and performance management
• GenAI-powered LMS and agent assist: Implemented a GPT-based learning and knowledge management system to digitize over 1,500+ SOPs across 12 functional areas with robust document and change management, ensuring compliance, version control and seamless audit readiness. GenAI-powered agent assist provides real-time, SOP-backed responses and next-best actions to the teams
• AI/ML intelligent document processing: Digitized and streamlined paper-heavy processes such as enrollments and plan changes
• Automation-first operations: Deployed 50+ RPA automations early post go-live for reliable, failure-proof automation, with AI/agentic capabilities being incrementally introduced. BPM supports dedicated queues for bots that auto-allocate based on triggers

• 20%–30% improvement in quality, with consistent achievement of Critical to Quality (CTQ) metrics across all functions
• ~60% reduction in manual errors, resulting in significant improvement in first-pass accuracy
• 100% adherence to the performance guarantee, ensuring that the client paid zero penalties
• 20%-25% cost optimization through scaled RPA-led automation, with emerging agentic automation capabilities contributing incrementally and 100% accuracy in bot-led transactions
• 20% efficiency gains enabled by GenAI-based knowledge assist
• Medicare enrollments and plan changes saw a 60% efficiency gain, significant quality improvement and a 33% reduction in Turnaround Time (TAT), all enabled by intelligent Optical Character Recognition (OCR)
• Enhanced broker experience (60% fewer complaints) through 50% reduction in inquiry response time

We remain committed to driving continued operational excellence and cost reduction through AI-led operations, enabling any health plan to achieve business goals faster and deliver experiential services to their members, brokers and providers.