Overview:

Process Redesign and Technology Enablement for a paperless enrollment and underwriting workflow for a Large, East Coast Healthcare Payer

Business Issue:

A backlog of applications resulted in 18% of all applications being delayed during a Medicare Advantage open enrollment, as there was no system in place to track and trace applications throughout the enrollment process. Membership applications would get misplaced and fail to be entered into the system for CMS approval. The problem created unsatisfied customers and overtime for staff members.

Engaged to review the current Med Advantage process, technology, and organization structure to identify root cause issues and develop and implement a repeatable process that could track and trace applications and eliminate root cause issues caused by Agents and the enrollment team.

Actions:

• Discovered the most frequent root cause throughout each step of the process.
• Mapped and diagramed the process to determine where inefficiencies were placed.
• Developed improved and scalable procedures to provide a valid process to follow the applications throughout the enrollment process.
• Collected information and documentation for better communications with the Agents.

Results:

• Created a database to track the applications by establishing a count. The database exposed missing applications when the count did not total correctly.
• Developed training documentation as job aids for temporary help during the peak season.
• Created job aids for Agents.
• Prepared pdf versions of Drug and Health applications for improved legibility.
• Implemented stricter guidelines for the Agents to follow including regulations in communicating the status of the application.
• Created a staffing model to incorporate temporary resources during the open enrollment season.