Transforming Healthcare CX With Automation, AI, and Smarter Routing

Impact Snapshot

The Challenge

Health plans operate in an environment where member expectations continue to rise, but legacy contact center models make it difficult to deliver consistent, high-quality support at scale. This health benefits provider was no exception. Daily call volumes ranged from 12,000 interactions to more than 20,000 during peak periods, straining both staffing models and operational budgets.

Members often faced friction when trying to reach the right resource because the existing IVR and routing processes were outdated. At the same time, lengthy and expensive training cycles slowed onboarding and made it difficult to keep pace with seasonal demand. As the program grew, inconsistency in service quality and escalating costs created additional pressure.

The organization needed a CX model that could reduce manual effort, improve speed and accuracy, and remain compliant with healthcare and member privacy requirements—all without disrupting the member experience. Most importantly, they needed an operational foundation that could scale predictably, absorb volume spikes, and lower overall program costs.

The Solution

To build a CX model that could scale with demand and reduce operational strain, Five Star Solutions partnered with the health benefits provider to modernize every layer of the member support experience. The approach combined automation, AI-driven tools, smarter routing, and workforce optimization into a cohesive transformation roadmap.

1. Automating High-Volume Member Inquiries

Five Star began with a detailed automation and operations intent study to identify routine calls that were ideal for self-service. High-frequency interactions—such as benefit balance inquiries, password resets, and card activation or replacement—were automated to free agents for more complex conversations and reduce overall manual effort.

2. Smarter Routing for Faster, More Accurate Resolutions

Outdated IVR paths were replaced with skill-based and predictive routing. Members were matched with the agents best equipped to resolve their needs, improving accuracy, reducing escalations, and shortening handle time. These routing enhancements created a more consistent, predictable experience for both members and agents.

3. Enhancing Agent Performance and Reducing Escalations

Improved CRM access and structured Tier 2 training equipped agents to resolve issues faster without passing calls to specialized teams. Real-time agent assist tools provided instant access to knowledge articles, FAQs, and automated call summaries—keeping agents focused on the member and accelerating issue resolution.

4. Accelerating Training With AI-Simulated Learning

To address long onboarding cycles, Five Star introduced AI-driven, simulation-based training modules that condensed five days of instruction into just three. Real-time coaching and standardized quality frameworks reinforced faster learning without sacrificing service consistency.

5. Workforce Management Optimization for Peak Scalability

Finally, automated workforce management tools enabled the program to better align staffing with historical volume patterns. This ensured the right coverage during high-demand periods while reducing excess staffing during slower times—creating a more scalable and cost-efficient operational model.

Together, these improvements formed a modern CX foundation that delivered faster service, greater accuracy, and lower operating costs—all while creating a better experience for members and agents.

These outcomes represent only part of the impact. Here’s how each area of the operation improved in detail:

Speed & Service Quality

Efficiency gains were evident across every step of the member journey. Intelligent routing and expanded CRM access produced a 12% decrease in handle time and a 10% increase in first-call resolution, giving members faster, more accurate support. Standardized workflows and real-time coaching contributed to a 5% improvement in quality scores, strengthening both compliance and consistency.

Cost Savings

The program saw a 30% reduction in overall costs for live-agent interactions as automation absorbed high-volume, repetitive inquiries. By shifting 20% of total call volume to self-service, the organization reduced reliance on expensive manual work and improved budget predictability across peak and non-peak periods.

Scalability & Workforce Agility

AI-driven, simulation-based training reduced onboarding time from five days to three, enabling the organization to ramp new hires 40% faster. Workforce management automation ensured staffing levels aligned with real demand, driving a 30% improvement in agent utilization and reducing the need for excess seasonal labor during high-volume periods.

The combined impact of automation, AI tools, and optimized operations gave the health benefits provider a scalable support model capable of handling unpredictable spikes while maintaining high service quality. The transformation also unlocked long-term value—lower costs, faster resolutions, and a stronger foundation for ongoing innovation.