Managed Care Organizations, an Opportunity to Redefine the Employee Experience
strategy, process, technology & workplace

For Managed Care Organizations, adjusting to a remote resource pool presents an opportunity for long-term strategic change

Our perception and expectations of the workplace are being tested in real-time as we adjust to a remote work environment. Many industries and companies are having to figure out how to collaborate, stay productive, and support their market and customer positions with a distributed workforce and resource pool.

Nowhere is this more important than in the healthcare industry, where employees and their organizations are on the front lines of responding and supporting us through the COVID-19 pandemic. Managed Care Organizations (MCOs or Health Insurance providers) are a vital part of our healthcare system. Like the rest of us, they are rapidly embracing a new reality of having to support their members and providers from home while ensuring they are even more responsive, customer-facing, and efficient. Some MCOs may have already invested in robust continuity plans and extensive infrastructure to support a remote workplace in case of a disaster. Still, I suspect none considered a disaster of the scale of COVID-19, where everyone is affected so dramatically. As we recover and begin returning to “normal,” MCOs must consider how to prepare for the next wave of COVID-19 or another similar pandemic or unplanned disaster  – I review three broad areas of focus below

  • People and Culture
  • Process Resiliency
  • Technology Foundation

These areas can collectively lead to an improvement in the service provided to MCO customers – Members and Providers – lasting far beyond our current pandemic.

People and Culture

COVID-19 is forcing us to test the waters of a fully remote workforce, and we should not think of it as a short-term solution. Instead, we should consider this as the start of a new way of collaboration going forward that can dramatically improve the service provided to members and providers if implemented strategically.

While there are challenges with a flexible and remote workforce, recent data show many employee benefits, including enhanced performance, improved morale, and improved effectiveness.

Core operations roles for MCOs – member and provider support as an example – have parallels to other shared-service customer service and call-center functions.  Therefore, they have existing use-cases and supporting platforms to enable remote work flexibility.  Call-center, and service work, in general, can quickly become isolating without a culture aimed to drive interaction and collaboration.  Finding the right balance of flexibility, establishing methods to manage the work, building the sense of a team, and tracking progress for individuals as they grow their careers becomes the challenge is required to foster success in remote work environments.

Figure 1: RingCentral Study, Benefits of Remote Work

Figure 1: RingCentral Study, Benefits of Remote Work

However, more specialized roles – such as Utilization and Care Management, Compliance, and Quality and Process Improvement – require more thoughtful planning.  They take a more direct interaction with other team members and have more tailored processes that present unique challenges to a fluid workforce.  That said, even these roles can thrive with flexibility so long as there are ways for constant interaction, defined expectations of performance, defined and formalized remote work policies, and provide ways to collaborate with other team members, whether at the office or home.

Lastly, company leadership must also embrace the new fluid, flexible, and remote workplace by establishing clear policies, ensuring that talent development processes account for the new environment, and build regular communication and feedback activities with their teams.

Investing in building a culture that enables workplace flexibility to thrive can have some tangible benefits for MCOs, notably:

  • The ability to create a more scalable workforce able to handle dynamic shifts in demand and
  • Broadening talent sourcing pool and increasing the attractiveness of critical roles thus improving the overall talent of the organization
  • Improving work-life balance and culture which has proven to improve retention, on-the-job performance, and most importantly the overall experience for Members and Providers

Process Resiliency

In addition to a well-defined set of culture and people activities aimed at driving a more flexible workplace, MCOs must also review and refine critical processes to adapt to this new model.  Existing processes, many of which assume face-to-face or manual interfaces – often with points of failure – need to become more resilient and adaptable to support a dynamic workforce and unpredictable demand that events such as the COVID-19 pandemic bring.  A few processes to consider include:

Authorizations – processing authorizations for services is a foundational process that must continue and can dramatically increase in volume during large-scale pandemics or emergencies. Ensuring this process can scale through automated review/approval, establishing an emergency “fast lane,” and building virtual medical review or member/provider interaction capability into the processes is vital.

Claims – much like the Authorization process, ensuring claims are processed and paid during emergencies is crucial to maintain the strength of the overall healthcare system. Thinking about how to remove bottlenecks, make the review and approval of claims more seamless, develop exception reporting to focus on issues, and digitize manual or cumbersome parts of the process can help to drive vertical (demand) and horizontal (distributed workforce, new services) scale.

Operations and Support – Member and Provider support are two of the most vital processes, especially under heavy or unexpected load, and often require a material number of employees. These employees and set of support processes represent the closest and most visible touchpoint with an MCOs customer, which, during a pandemic, can directly impact the wellbeing of a member.  Driving self-service across these processes is an essential first step while also including methods for work to be virtually managed, digital interactions between teams and customers, and developing rapid-response crisis teams will also improve resiliency and flexibility in the support processes.

These are just a sample of crucial processes that MCOs should consider optimizing in the long run. If done, they can thrive under a remote and flexible workplace as well as better support unexpected events such as this novel coronavirus.

Driving scale and resiliency in core operational processes have direct benefits to serving the members, including:

  • Ensures that members have the support they need at the most essential times
  • Allows an organization to maximize the use of its existing resources by dynamically shifting load across locations, taking advantage of otherwise unproductive time (drive-time), and enabling on-demand scalability
  • Adds potential to leverage lower-cost resource pools as key processes will require less, ideally no, in person or manual intervention

Technology Foundation

Enabling a remote and flexible workforce with resilient and scalable processes requires a technology foundation built to allow for those capabilities but, unlike most remote work discussions that often start and end with technology, we believe it’s one part of a complete solution.

There are many aspects to a robust technology architecture to enable the workplace of the future, and we’ve outlined a sample reference architecture to describe some of them.

Figure 2: Trans4mative SaaS & Cloud Architecture Reference Model

MCOs have some unique and challenging technology requirements to consider as they aim to begin adapting to and building a long-term remote work capability for their employees.  Like the broader healthcare industry, there are strict requirements around security.  Often organizations focus so much on security that it negatively impacts the productivity for remote workers and negates the anticipated benefits.  There are modern approaches to security that allow for compliance (HIPAA, HITRUST, PCI, etc.) but also enable a more seamless experience for the end-users.  The combination of modern SaaS tools and services, API-based integration platforms, next-generation AI and automation capabilities, and advanced identity management services can be combined to create a robust enterprise architecture.   This type of robust architecture can better scale with demand, create an integrated experience for users, and enable a more efficient work environment comparable to being in the office.

Building a modern enterprise architecture focused on delivering a simple and engaging experience for employees no matter their location can have direct benefits to the customer experience, such as:

  • Improved and more seamless internal processes directly improve the customer experience
  • Employees empowered to work in their best environment will outperform the average and provide better overall service to their members and providers
  • New technologies can enable and drive automation, and thus efficiency gains, in traditional processes requiring manual labor

The Opportunity

Our collective experience with the COVID-19 pandemic will shape the way work is performed long into the future.  Remote work is not a new or novel concept. Still, the past few months – and coming few, unfortunately – are going to permanently change our perception of productivity and what remote workers can achieve.  I believe that what we are doing now is proving this model can work – and does work – and having had this experience, workers will come to embrace and expect this capability even after we recover.

Beyond creating a better internal experience for employees, investing in a modern and flexible workplace will lead to better experiences and outcomes for members.  MCOs that focus on establishing this culture and capability will have a competitive advantage in attracting and retaining higher-caliber talent, being prepared for future uncertainty, and delivering a more comprehensive and efficient experience to their member and provider population.

We believe the Future of Work is a flexible one where employers enable their employees and provide a space for them to grow, be productive, and innovate in whatever environment best suits them.

Trans4mative has experience in leading companies through this change, from defining an achievable and measurable strategy through execution and adoption.  We can accelerate this journey for your team, and if you would like to discuss what that looks like, please contact me directly below.

Access all of Trans4mative’s resources for adapting your workplace for increased remote working here. 


Partner @ Trans4mative Advisors

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