The Best Member Experience Is the One Members Never Notice
Health plan members expect healthcare to work the same way everything else in their lives does: quickly, accurately, and without unnecessary effort. But behind the scenes, enrollment, claims, and customer service processes have historically relied on manual steps, fragmented data, and exception-based fixes - creating friction that ultimately reaches the member.
enGen’s Core Administrative Processing System (CAPS) changes that. By embedding automation and AI directly into its operational backbone, CAPS removes issues before they affect members - improving experiences without adding complexity or burden for frontline teams.
“The goal isn’t to add more technology on top of broken processes. It’s to redesign how the work happens so problems are prevented upfront and members never experience the friction at all.”
-Mike Stimpson, Chief Technology Officer at enGen
Eliminating Problems Before Members Feel Them
Consider a common scenario: Johnny Jacob Jr. enrolls in coverage under the same plan as his father, John Jacob Sr. Without strong identity controls, similar names and shared addresses can create duplicate records, misapplied claims, or enrollment delays - often discovered only after a member encounters a problem.
With CAPS automation, those conflicts are resolved upstream. Identity discrepancies are automatically detected and corrected, ensuring accurate enrollment records and clean claims processing. In Johnny’s case, the system distinguishes him from his father immediately so coverage, claims, and communications work as intended without intervention or delay.
Enrollment: Automation Starts at the Front Door
Enrollment is one of the most critical - and historically manual - moments in the member journey. Paper forms, handwritten fields, and incomplete data have long required labor-intensive review and correction.
enGen’s CAPS addresses this challenge with EZEnroll, which digitizes and automates inbound enrollment applications. Using AI-driven data extraction, EZEnroll converts unstructured forms into ready-to-process transactions with 95–96% accuracy. Quality-check time is reduced by 65%, dropping from 10 minutes to just 3.5 minutes per application and freeing staff capacity for higher-value work.
As enrollment volumes scale toward 80% digital intake, EZEnroll ensures accurate data flows seamlessly into downstream membership, billing, and claims processes. Automation begins on day one - setting the foundation for smoother experiences throughout the member lifecycle.
“Enrollment data sets the tone for everything that follows. If you get that first step wrong, you pay for it repeatedly downstream. Automating the front door changes the economics - and the experience - across the entire system.”
-Mike Stimpson
Claims: Intelligent Automation at Scale
Once claims enter the system, automation continues with ACE, the AI Claims Examiner. ACE analyzes suspended claims, identifies patterns, and recommends resolutions with consistency and auditability - processing high-confidence scenarios automatically and accelerating complex cases for review.
With machine-learning models supporting member matching, duplicate detection, and rule-based checks at 99.64% accuracy, ACE has resolved more than 2.19 million suspended claims, cutting resolution time in half.
For operations teams, this reduces repetitive manual effort and cognitive load. For members, it means faster decisions, fewer errors, and less financial uncertainty.
In Johnny’s case, claims are correctly matched to his record - not his father’s -avoiding delays caused by identity ambiguity and ensuring timely, accurate outcomes.
Customer Service: Closing the Loop with AI
Even with strong upstream automation, members sometimes need to call. When they do, CAPS continues working behind the scenes through AI‑powered after‑call summaries.
These summaries automatically generate structured, consistent documentation after each interaction - eliminating manual note-taking and allowing service representatives to focus fully on the member conversation. The result is more empathetic interactions, quicker resolutions, and smoother follow‑up across teams.
Supporting 1,500 customer service users and generating 1.6 million summaries in a single year, this capability saves an estimated 27 seconds per call - equating to $1.1 million in annual operational savings. More importantly, it creates a reliable data foundation for identifying trends and preventing repeat calls before they happen.
A System That Works Together So Members Don’t Have to Think About It
Individually, enrollment automation, claims intelligence, and AI-driven service tools deliver meaningful value. Together, they form a self‑reinforcing automation ecosystem:
- Clean enrollment data leads to more accurate claims
- Accurate claims reduce the need for service calls
- High-quality service documentation improves future decisions
“We built an integrated system where each improvement amplifies the next. And the member benefits at every step.”
-Mike Stimpson
CAPS automation eliminates administrative friction, strengthens employee performance, and continuously improves outcomes across enGen’s health plan clients.
For members, it simply feels like things work the way they should.