Overview‍

One of the nation’s largest not-for-profit Medicaid and Medicare health plans serving nearly 2 million members sought to enhance member support with a scalable, digital-first solution. Committed to delivering quality healthcare to underserved communities, the organization implemented Ushur's AI Agent for Member Service to facilitate interactive chat-based service requests on their website. The agentic solution quickly exceeded expectations, improving member engagement and streamlining operations through convenient, HIPAA-compliant self-service.

Challenge‍

The health plan faced staffing challenges in managing seasonal surges in call center volume, particularly during Medicaid renewals and open enrollment periods. Members largely relied  heavily on phone calls for assistance. A scalable, digital-first solution was needed to handle routine as well as complex inquiries, with specific goals to improve access to health plan information, reduce the staffing strain, and provide 24/7 support to members outside of member service operating hours.

Solution‍

The organization implemented Ushur’s AI Agent for Member Services, a HIPAA-compliant solution that services member requests. Leveraging domain-specific AI and existing plan knowledge bases, Ushur's AI Agent provides personalized, empathetic support, enabling members to quickly resolve inquiries and service requests, access accurate health benefits information, and receive assistance around the clock — including outside of core business hours during weeknights and weekends. With built-in compliance safeguards, the solution ensures HIPAA-secure data handling while reducing operational strain. By automating high-volume interactions, Ushur’s AI Agent improves accessibility, accelerated response times, and optimized member service without compromising quality.

Key Capabilities

• 24/7 Omnichannel Engagement: Available around the clock across digital channels, ensuring timely, HIPAA-compliant support, particularly during peak demand periods.
• End-to-End Automation: Integrated with third-party systems, automating processes to reduce manual workloads and improve efficiency.
• Robust Security and Compliance: Adheres to HIPAA and HITRUST standards, ensuring the security of sensitive health data.
• Human-in-the-Loop: Facilitates real-time escalation to live agents during member interactions, ensuring consistently high-quality outcomes.

Impact‍

Ushur’s AI Agent delivered tangible, measurable results, significantly enhancing member service operations. Within the first two months of deployment, the AI Agent:

• Handled 18% of web traffic through seamless self-service, reducing live agent support.
• Automated 21% of requests for four top call drivers — Member ID card requests, Primary Care Provider (PCP) selection, address updates, and contact information updates — streamlining common inquiries.
• Resolved over 36,000 interactions autonomously, alleviating pressure on member service teams and improving efficiency.
• Delivered over 20% of responses outside business hours, ensuring members received timely support whenever needed.

Additionally, the organization leveraged Ushur Insights to access valuable analytics about member service needs, identifying the most frequently asked questions. The top three inquiries addressed by Ushur’s AI Agent in the first two months were related to emergency care, member ID, and coverage.

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Interestingly, 10% of AI Agent interactions addressed sensitive topics, with the top three by volume related to housing assistance, sexual and reproductive health, and mental health services. This trend highlights Ushur’s AI Agent as a trusted, private resource for critical issues, underscoring its potential to serve as a secure and equitable means of improving access to vital health information.

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Future Outlook‍

The organization continues to expand Ushur’s AI Agent capabilities, increasing its knowledge base and integrating it with call center systems to enable seamless escalation to live agents. As part of its ongoing digital transformation, the AI Agent is being leveraged to enhance the overall member experience with more personalized, efficient, and secure support.