The Challenge

The health plan delivers affordable, high-quality healthcare products to over 1 in 15 Americans, including Medicaid and Medicare members (with Medicare Prescription Drug Plans). Navigating Medicaid’s complex, state-specific regulations while ensuring vulnerable populations receive consistent, high-quality care is a top priority for the organization. Key objectives include maintaining stringent quality, reducing AHT, increasing CSAT, decreasing DSAT, and lowering language line costs to ensure efficient, compliant, and member-centered care.

The Solution

Over nearly two decades, ResultsCX leveraged its deep Medicaid expertise to proactively support the health plan’s members across through an education- and empathy-led approach. The solution focused on proactively anticipating challenges and providing solutions–strengthening agent capability, standardizing best practices across platforms, and improving access to care for vulnerable and transient populations–all while navigating complex, state-specific regulations.

• Enabled Persona-based agent coaching and established a bilingual pod to tailor support to individual member needs.
• Launched an Intensive Care Unit (ICU) to preemptively identify performance outliers and scale best practices across states, driving consistent quality and customer satisfaction.
• Ensured Regulatory compliance testing, agent coaching, and outcome tracking to ensure adherence and drive continuous performance improvement.
• Piloting a secure, real-time AI translation solution to eliminate language barriers, reduce costs, and improve member experience.
• Leveraged AI-enabled training videos to accelerate agent readiness.
• Hosted meet- and greet forums to align agents with client priorities and increase productivity.
• Educated members on CSAT surveys to improve participation and response quality.
• Verified member address and coordinated transportation for uninterrupted care access.

The Customer

A leading healthcare enterprise that delivers government-sponsored health programs, providing affordable, high-quality care to millions of members across Medicaid, Medicare, and the Health Insurance Marketplace. Focused on improving health outcomes and reducing costs for underserved populations, the organization leverages data-driven care management to deliver localized health plans.