Claims Assistant
Health Insurance Claim Virtual Assistant
My Role
Lead Conversation Designer
My Team
User Researcher, Integration Architect, Product Owner, Engineers
Project Length
10 months
Context
The self-service virtual assistant diverts routine inquiries—such as claim statuses, detailed claim information, and financial breakdowns—away from call centers.
Problem
Despite the availability of online resources, health insurance members frequently encounter difficulties in obtaining clear and comprehensive information regarding their claims. The legacy Interactive Voice Response (IVR) system for this health insurance company was underperforming, with customer surveys consistently indicating dissatisfaction due to its lack of clear and detailed claim information.
In Numbers
The assistant fields 57,284 calls a month
63k in cost savings a month
User Research
Deliverable: User Personas
Objective
Understand customers’ needs, frustrations, and expectations with managing health insurance claims. My research ensured that the design would meet the diverse needs of our user base. By grounding our design in detailed, research-based personas, we aimed to enhance user engagement, improve satisfaction rates, and ultimately drive successful adoption of the virtual assistant across various member demographics.
Methods
Existing Surveys
Interviews
Call-listening
Transcript analysis
Focusing on apprehensions or pain points to empathize with member perspective
Deliverable: User Journey Map
Objective
Gather insights from internal stakeholders, speak to members about their health insurance claims experiences. Also met with SMEs (e.g. claims adjudication SMEs, customer service representatives, IT staff) to understand when customer touch points occur.
Methods
Facilitate discussions and semi-structured interviews with business SMEs
Focus on future and current challenges in handling claims inquiries
Drill down into virtual assistant expectations
Health Insurance Claim User Journey Map
Design Exploration
Sample Dialogs
Draft dialog as early as possible to start iterating on language and identifying potential flows.
Project Reflection
This was a highly complex and heavily regulated use-case.
Challenges: Health insurance claims involve personal health information (PHI) and personally identifiable information (PII) special attention is needed when thinking about authentication levels of information.
The following attributes informed our design strategy: privacy-centric, seamless, intuitive.
The dialog above was not shipped because technical limitations didn’t allow for predictive personalization and leveraging member context early enough in the experience. We instead needed to collect the date of service for the user’s claim to unlock the member data in back-end services.
This dialog was shipped and is currently in production. Prompts highlighted in green indicate a change from the “ideal“ UX shared above.
Design Documentation
Dialog Flows
Creation of conversational user flows in a large matrixed environment requires orchestrating a partnership with engineers, technical leads, solution architects, integration architects, and technical business analysts. I crafted precise and clear specifications, ensuring that the solution was both innovative and aligned with strategic business objectives.
Outcomes
There was an increase in customer satisfaction, we modernized the enterprise product offering.
In Numbers
Current call volume is 4k per month
70% customer satisfaction (The caller was asked “Were you satisfied with the service you received today?“)
74% customer experience (The caller was asked “Was the [Health Insurance Company] Virtual Assistant easy to work with?“)
