Improved member and provider experience
Increased efficiency
Scalable model
Mastering the Momentum of Technology in Healthcare
As a leading health insurance provider, our customer wanted to improve their member and provider experience by leveraging AI to optimize their customer success representative (CSR) workflows.
Simplifying Information Access
Diagnosing a CSR System
The health insurance provider wanted to improve their overall member and provider experience by enhancing service efficiency, improving accuracy and reducing resolution time. They envisioned an agentic platform supporting CSR workflows powered by Salesforce Agentforce. The goals? More satisfied members and providers and an enhanced experience for CSRs thanks to an agentic solution eliminating the “swivel chair” to access information and tools.
Establishing a Unified CSR Platform
Charting a Clear Path to System Health
Our customer’s commitment to their members and providers is underscored in their quest for continuous improvement. They strive to make life easier when supporting members and providers by understanding their claims and overall benefit plans through streamlined processes and systems.
Enter TGS, a Salesforce Summit Partner with deep Agentforce expertise and over 150 AI certifications. Our long-standing partnership with this insurance provider across Salesforce initiatives, as well as our AI leadership and proven domain expertise, set this engagement on a path of strategic collaboration and innovation.
Implementing an Intelligent Agent
Enhancing Member Support
Our top priority was enabling CSRs to quickly access the status and details of claims and associated benefit plans. We developed an intelligent agent with Agentforce that retrieved:
- Claim status
- Creation and update dates
- Copay
- Billed and approved amounts
- Benefit plan lookups and plan details
With secure API integration and strong compliance guardrails, the AI agent provided CSRs with detailed Member360. Our team implemented real-world testing with CSR feedback to ensure the agent properly retrieved narratives based on plan, category and effective date.
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Real-World Results
The implementation of a custom-designed intelligent agent improved member and CSR experiences, leading to high satisfaction for both parties. Plus, rapid deployment and adoption meant faster time to value.
The organization experienced additional value impacts, including:
- Efficiency gains: CSRs could now handle more calls with quicker resolutions.
- Increased member and provider satisfaction: Accurate, timely responses led to more satisfied end customers.
- Scalable model: Agentforce use cases were replicable across other healthcare payers.
- Continuous value: Agents allowed for additional functionality, taking action for further automation and efficiency gains.
Our partnership with the customer continues as our team explores more use cases and capabilities for the organization’s Agentforce implementation. Together, we’ll enhance support and operational agility, satisfying members and CSRs.
