Transforming Healthcare Member Enrollment, From Weeks to Just Minutes

Overview

Sky Solutions supports digital transformation for a large regional healthcare payer serving approximately 1.5 million members. Like many healthcare payers, this organization (the client) is committed to modernization initiatives aimed at improving healthcare access and enhancing the member experience. A critical part of this mission is the organization’s ability to respond quickly and efficiently to market changes and member expectations, ensuring members continue to receive timely and seamless access to their preferred healthcare options. One area within the health insurance industry that has long been a prime target for digital transformation—offering opportunities to significantly reduce costs, eliminate waste, and improve the member experience — is the member enrollment process.

Goal

The organization sought to enhance the member experience by streamlining the enrollment process, ultimately reducing the enrollment timeline, decreasing case resolution times, and boosting Enrollment Processor productivity.

Challenge

Outdated member enrollment processes and technologies posed numerous challenges, including manual, paper-based workflows, lack of integration with other systems and data sources, limited accessibility, increased administrative burden, increased compliance risks, and a poor member experience.

For over a decade, the client relied on Lotus Notes, a legacy CRM and ERP system, to support many critical business functions, including member enrollment. Enrolling a new member historically took anywhere from several days to a few weeks, involving multiple manual steps and requiring access to and interaction with various disconnected systems and data sources. This resulted in frustration and delays for members, data inaccuracies and discrepancies, decreased member acquisition and retention, and ultimately threatened revenue targets. It became clear that Lotus Notes could no longer provide the functionality needed to effectively address these issues.

Solutions

Sky Solutions assisted in migrating the member enrollment process from Lotus Notes to a modern, low-code, cloud-based system—Pega—that streamlined and automated several enrollment functions. The new platform enabled integration of the necessary disparate systems and data sources critical to the process, provided reporting and visibility into the reengineered workflows, and allowed for rapid scalability and adaptability for the future.

Technologies Used

  • Low Code
  • Agile
  • DPA
  • Pega
  • Cloud 

Outcome

Since the new enrollment function on Pega went live over a year ago, the total enrollment timeline has decreased from several days or weeks to just a few days—or even minutes in some cases. Case resolution time has been reduced by approximately 86%, and Enrollment Processor productivity has increased by 95%.

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