Digital Transformation in Managed Care: Streamlining Compliance and Enhancing Member Trust

In this interview, Jordan Armstrong, chief revenue officer at ResultsCX, discusses how leading health plans are leveraging artificial intelligence (AI), automation, and personalized advocacy to simplify compliance, strengthen member trust, and transform high-stakes interactions like prior authorizations and appeals into opportunities for loyalty and engagement.

Please introduce yourself by stating your name, title, and any relevant clinical experience you’d like to share.

Jordan Armstrong: I'm Jordan Armstrong. I am the chief revenue officer at ResultsCX. We are a customer experience organization, and a large proportion of our client base today is based in the health care realm. That's where I've spent a large amount of my career.

How are leading health plans using digital tools to navigate the growing regulatory complexity without compromising the member experience?

Armstrong: This is a very relevant question, given everything that's going on within our markets and also the economy from that standpoint. I would say at a macro level, leading health plans are leaning in on digital tools. How can they use that to navigate regulatory complexity without compromising that member experience? They are turning compliance into a catalyst for innovation.

If I were to focus in on 2 areas, the first area, from an automation and artificial intelligence (AI) compliance standpoint, is there are several examples of plans that are using AI and machine learning to streamline those traditionally complex processes, such as claim adjudication and prior authorizations. It not only reduces the administrative burden but also improves turnaround times for the members.

For example, a national health plan has partnered with Salesforce Health Cloud to integrate physician electronic health records (EHRs), enabling near real-time prior authorization decisions. Similar to that, several large health insurers have deployed AI that can auto-approve requests instantly when decision criteria is met, drastically cutting down on wait times and back and forth with those providers. To that end, the Centers for Medicare and Medicaid Services (CMS) itself has launched pilots to test AI in prior authorization. This is signaling how critical digital innovation has become in the health care world of compliance.

The second area that I would stress is around how to personalize digital engagement. A lot of health plans are using data-driven platforms to create a more member-centric experience. One strong example is a national insurer that has built self-service applications and proactive communication tools delivering reminders about preventive care, chronic condition support, and price transparency insights.

This empowers the human advocate, powered by AI, so that they can spend less time searching for answers and more time engaging with their members on high-value and empathetic conversations. In some cases, those advocates intercept members before they even schedule an expensive procedure, guiding them to potentially lower-cost but equally effective care alternatives.

Health plans are leaning in and leveraging digital tools not just to stay compliant but to find ways to operate more efficiently and deliver a faster, more transparent, and personalized experience for their members.

In what specific ways have recent regulations around prior authorizations or network adequacy impacted member trust, and how are successful plans responding?

Armstrong: From a regulations standpoint, prior authorization and network adequacy have had a real impact on overall member trust because they touch the most personal part of health care—and that's the experience around timely access to care.

First and foremost, on the member side, prior authorizations are often perceived as a barrier to care. When those requests are delayed or denied, it creates a sense of frustration and feeling that the plan is standing in the way rather than supporting that member.

Adding to that is a lack of transparency. When denial reasons aren't clearly communicated to the member, it further fuels that confusion and suspicion. Finally, the administrative burden of navigating appeals can leave members feeling unsupported and overwhelmed, further eroding that trust.

The plans that are responding well are the ones that are leaning into technology, transparency, and empathy. These plans are streamlining the prior authorization process, leveraging digital tools and real-time electronic responses to cut through those delays. They're also looking at avenues to improve communication by providing clear and personalized explanations when there is a denial and by outlining, in plain language, what the true next steps are. Some are even reducing the number of services that require prior authorization in the first place, particularly in areas of routine in-network services, which is removing unnecessary friction.

Another important step is the continuity of care by honoring prior authorizations when a member changes plans mid-treatment so that treatment isn't disrupted for that patient and member. Another great example of this is the gold card programs adopted by some major health insurers. For providers who consistently show high approval rates—say, 90% or higher for multiple years—prior authorization requirements have been waived altogether.

This builds trust not only with providers but also with members. There are subsequently fewer delays and less red tape in getting the necessary care. In short, the plans that are getting it right are reframing compliance as an opportunity through leveraging digital tools and smarter policies to create that faster, clearer, and more member-centric experience.

What role does member advocacy play in maintaining loyalty, especially as consumer skepticism toward payers continues to grow?

Armstrong: Member advocacy is becoming a critical strategy for maintaining loyalty during a time when consumer skepticism against payers is at an all-time high. It goes well beyond traditional customer service. It's about providing personalized, proactive support that helps members navigate a very complex health care system. If I were to break it down, I would probably focus in on 4 areas where advocacy can have a real impact.

First, in building trust and empathy, a dedicated advocate or concierge service gives members a true human connection in what can otherwise feel like a faceless bureaucracy. That relationship builds confidence and shows the plan is invested in the member's wellbeing.

The second area is how to help them navigate complexity. Health care is very overwhelming, even for an educated buyer. Advocates can help members understand their benefits, find in-network providers, and work through complicated processes such as prior authorizations or even appeals. This not only removes the roadblocks but also empowers the members to make better and smarter decisions about their own care.

The third bucket is how health plans can become more proactive. Instead of waiting for a call when something goes wrong, advocacy programs are using data and insights to reach out in advance of those interactions. Whether it's a reminder about a preventative screening they need or a suggested lower-cost, more convenient care option for that member, the proactive outreach improves the overall outcome and signals that the plan is looking out for the member.

The fourth and final bucket is improving outcomes and rising costs. By guiding members to the right care at the right time, advocates can reduce unnecessary spend while still improving overall care adherence and outcomes. It becomes a win-win for both the plan and the member. One of the examples that I would cite comes from a Pennsylvania-based health plan that created a virtual concierge capability using Amazon Alexa. Members can ask questions about coverage or benefits through their smart speakers and get instantaneous answers. It provides their members with a 24/7 self-service option that not only continues to improve convenience and satisfaction but also frees up their human advocates to focus on member needs that are more complex.

These areas show that advocacy isn't just about a service add-on; it is becoming a differentiator among payers across the US. The health plans that have successfully woven advocacy into their interactions are redefining what it means to be a trusted partner. They are shifting that perception from the insurer to the true ally of health care in the face of their membership.

How can health plans better leverage tech-powered communication strategies to improve satisfaction, especially during high-stakes touchpoints like appeals or denials?

Armstrong: When we look at high-stakes touchpoints such as appeals or denials, they're defining moments as it relates to building member trust.

A denial letter can feel cold or confusing and can further alienate a member. When we look at technology-powered communication strategies, plans can leverage this to turn these moments into opportunities and reinforce transparency and support of their members.

Again, if I break it down into key ways that plans can do this is, first and foremost is clear and personalized digital communication. Instead of sending out that generic denial letter, plans have the opportunity to deliver a personalized text or an email in plain language summarizing that decision and explaining what the next steps are in a way that feels supportive vs bureaucratic.

The second way plans can do this is through an interactive digital appeals process, making sure that they have user-friendly portals that can walk members step by step through those appeals with checklists, automated digital reminders, and secure document loads. These are all designed to simplify the overall process, making it much less intimidating for their members.

Third, plans can utilize AI chatbots and frequently asked questions (FAQs). There are several examples out there where plans are using intelligent chat tools that can answer common questions instantly for a member, reducing frustration and giving members confidence that help is available on demand at their convenience.

Finally, plans should make sure that there's a seamless handoff through that process. When members need more complex support, technology can enable a warm transition to a human advocate by passing along the case details so that members don't have to repeat their story over and over again. That blend of automation plus human empathy is where trust can be built.

For example, one national health insurer is using analytics and AI to personalize their communication pathways for each of their members. A family plan holder might receive a pediatric care guidance, while a member with diabetes could get reminders about their checkups and in-network specialists available to them. The plan has been able to show that the plan not only understands individual needs, but it’s also proactively supporting the next step of each member's health journey.

The key takeaway here is there needs to be a combination of digital precision and human empathy, in which successful plans transform appeals and denials from moments of frustration for their members into opportunity to build that lasting trust and loyalty.