One of the largest not-for-profit health plans in the nation, serving nearly 2 million Medicaid and Medicare members, has embarked on a transformative journey to enhance member support using Ushur’s AI Agent for Member Service.
According to Ushur, this digital-first solution has not only met but exceeded expectations, significantly boosting member engagement and operational efficiency through interactive, chat-based service requests on the health plan’s website. The AI-powered tool ensures HIPAA-compliant self-service, catering effectively to underserved communities.
Previously, the health plan struggled with staffing issues, especially during peak periods such as Medicaid renewals and open enrollment. The reliance on telephone-based support meant that members often experienced delays. The need was clear: a scalable, digital solution capable of handling both routine and complex inquiries efficiently, thereby enhancing access to information, alleviating staffing constraints, and providing round-the-clock support.
The implementation of Ushur’s AI Agent for Member Services marked a significant advancement. This HIPAA-compliant tool leverages domain-specific AI to deliver personalized and empathetic support. Members can now swiftly handle inquiries and service requests, access accurate health benefits information, and receive assistance at any hour. The AI Agent integrates seamlessly with existing plan knowledge bases and third-party systems, facilitating end-to-end automation and ensuring data security while reducing operational burdens.
Ushur’s solution provides 24/7 omnichannel engagement, ensuring members have continuous access to support across various digital platforms. The system features robust security protocols compliant with HIPAA and HITRUST standards, safeguarding sensitive health data. It also includes a human-in-the-loop approach, enabling real-time escalation to live agents to maintain quality outcomes.
Since its deployment, the AI Agent has delivered impressive results:
It managed 18% of web traffic through self-service, significantly reducing the need for live agent support.Automated responses handled 21% of requests for common issues like Member ID card requests, PCP selections, address updates, and more.It autonomously resolved over 36,000 interactions, easing the load on service teams and enhancing overall efficiency.Outside of regular business hours, it provided over 20% of all responses, ensuring that members received help when needed.
Furthermore, Ushur Insights revealed that the most common inquiries during the first two months involved emergency care, member IDs, and coverage questions. Notably, 10% of interactions dealt with sensitive issues, including housing assistance and mental health services, highlighting the AI Agent’s role as a confidential resource for crucial health information.
Looking ahead, the health plan is focused on further enhancing the AI Agent’s capabilities by expanding its knowledge base and integrating more closely with call center systems. This ongoing digital transformation aims to refine the member experience, making it more personalized, efficient, and secure.
Keep up with all the latest FinTech news here.
Copyright © 2025 FinTech Global
Investors
The following investor(s) were tagged in this article.
