Call Center Services

The call center specializes in performing multiple roles, all directed at providing world-class customer service to the members, providers, and customers. These services include the following:

  • Welcome Calls – Welcome calls are made to the member and are the department’s way to thank the member for joining the plan, give them an overview of the program, and answer any questions that they may have regarding their new plan.
  • Health Assessments – Calls are made to the member and entail the call representative finalizing a health assessment, which enables the care management team to have specific information that will help in being proactive regarding treatment plans. A health assessment can either be included within the welcome call process or as a separate call.
  • Member Engagement – Based on a member’s response to health assessments or other criteria identified by the client, the team discusses case/disease management programs available to members in an attempt to drive case management participation. This alleviates the care management team’s need to focus on initial outreach. Throughout 2014, the team was able to maintain a 55% average acceptance rate during outreach to members with low, medium, and high risk acuity.
  • Demographic Research – In situations where a member’s demographics are not accurate and that do not allow the call center to be successful in making welcome calls or health assessments, the team calls primary care providers and/or the member’s pharmacy to obtain correct contact information.
  • Claim Benefits and Status – The call center team is able to provide detailed and accurate information regarding plan benefits and claim status for health plans. The types of plans handled by the team include Medicaid, limited medical, major medical, dental, life, and prescription plans.
  • Returned Mail Calls – If mail is returned, the call center performs the demographic research to obtain an accurate address so the mail can be redirected to the correct location.
  • Extended/Weekend Hours – When required by the client, the call center extends its hours beyond the normal call center hours and opens for weekends. The current call center hours are Monday through Friday from 8 AM to 8 PM Eastern.
  • After Hours Nurse Line – If the need arises, we have an After Hours Nurse Line where members are able to get quick answers to medical-related questions.

Emphasis on Quality

The call center places a high emphasis on quality. Through stringent hiring practices, thorough training, and continuous feedback, the department is able to achieve remarkable results for quality. The department’s average quality score for 2014 was 95.7% accuracy.

Results Driven

By proactively and aggressively managing the call volumes and queues the department is able to produce results that routinely exceed standards in place regarding abandonment rates and the speed to answer.

The following statistics show the 2014 service levels for inbound and outbound calls and the call volumes.

  Abandonment Rate
Standard <5%
Speed to Answer
Standard <30 Seconds
Total Call Volume
Jan-14 1.2% 11 21,808
Feb-14 0.8% 7 18,015
Mar-14 2.2% 19 23,024
Apr-14 1.6% 15 22,835
May-14 1.5% 15 23,362
Jun-14 1.8% 17 22,046
Jul-14 1.6% 19 23,163
Aug-14 1.5% 17 22,431
Sep-14 1.4% 15 27,906
Oct-14 1.7% 18 25,959
Nov-14 1.7% 14 18,827
Dec-14 1.4% 17 19,643
  Average Total
1.5% 15 269,019