Revolutionizing Member Services and Support through SmartBPM®

With competition intensifying and members taking an increasingly active role in their healthcare choices, payer organizations need to provide unparalleled, personalized service across all information channels. However, most organizations rely on antiquated legacy systems that cannot keep up with the demands of constant change in the healthcare industry.

Pegasystems' Member Services™ solution framework anticipates the needs of both the customer service representatives (CSRs) and of the members so that CSRs have the tools they need to deliver personalized and responsive services. This rules-based solution delivers the agility required in today's dynamic environment to quickly re-engineer member-facing business processes. It gives payer organizations the power to respond quickly to changes in organizational objectives, market opportunities and health industry regulations. With this power, they can achieve higher levels of CSR productivity, member satisfaction, and more efficient compliance with employers' service-level agreements.

Member Services Benefits

• 65% reduction in manual decisions
• 35% increase in issues resolved per contact
• 20% reduction in call wrap-up work time
• 50% reduction in CSR training time
• 26% reduction in call-handling time

Used in conjunction with our Provider Services™ solution framework, Member Services allows payers to create a fully-integrated, customer service center that will deliver even greater growth, productivity and compliance in a rapidly-changing environment. 

Member Services Key Features

• Interaction and activity management — Delivering comprehensive, relevant member information to a single screen view, Member Services eliminates time-consuming toggling between systems.
• Channel management — The application delivers service consistently and seamlessly across Web, e-mail, Computer Telephony Integration (CTI), Voice Response Unit (VRU), Interactive Voice Response (IVR), and more.
• Service management — Rather than routing or escalating work for manual intervention, Member Services uses pre-configured workflows to streamline contract-maintenance transactions, benefit inquiries, and claim status inquiries, eliminating processing errors and decreasing member callbacks.
• Offer management — Member Services enables CSRs to proactively offer new programs that promote member retention, Web self-service, and wellness programs — promoting healthier, happier members and lowering medical costs.
• Performance and compliance management — The solution extends managerial oversight across your customer service activities with comprehensive performance management, reporting, and self-documenting capabilities.
• Change management — Built on PegaRULES Process Commander®, this solution empowers business users to personalize processes efficiently to respond to changing business conditions.