2021 Top 25 Agent CX Success Stories
AGENT AWARD-WINNING CX STORY
Success In Adapting to Best Practices
“She goes the extra mile to improve her calls and ... goes above and beyond with each of her callers.”
Madeline is a true rockstar on our team. Every member that she speaks with receives the same level of respect, empathy, and urgency, whether they need an ID card, simple benefits, or have an urgent pharmacy request. There are many members who will only speak with Madeline and are willing to wait on hold or request a call back if Madeline is not available. Not only did Madeline have a 96% certification for 2021, but she achieved an 87% FCR rate, 96% in Issue Resolution, and 98% in Customer Satisfaction.
In sharing some of the comments left by our members below, you can clearly see that Madeline is valued and our members appreciate how effortless the experience is when they speak with Madeline. Members advise:
“She was very pleasant. She answered my question immediately and resolved my question immediately. She just made me feel very comfortable about calling and inquiring.”
“She was very nice. She didn't lose her patience with me. She went above and beyond to help me and let me know about stuff getting set up in the system, and where I could look at my claims. She took time to help me with everything, even things that I didn't know anything about. She took time to help me, and she did help me. That will cut down on me having to call them again for information, because I can look at it myself.”
“They were kind, courteous, understanding, and they even followed up on the issue today to confirm.”
“Just very kind, took care of the issue, and she actually called my previous employer to speak to their representative and had me on the line just to make sure that they were getting everything I needed.”
Even when Madeline is pulled in many different directions during the day she does so with grace and kindness, and it is evident in her scores. She is also extremely helpful to her peers, assisting with answers to challenging member scenarios in the Team Chat, and no matter how difficult a member’s issue may be, Madeline is always very kind, gentle, and determined to resolve the issue. Madeline is more than deserving of this award.
At BlueCross BlueShield of North Carolina, we identified an area where we could improve our FCR, CSAT, and Resolve Rate results from the SQM Call Summarization Best Practices materials. We followed a standard closing, but wanted to improve the experience for our members to ensure first call resolution, so we refreshed and improved our agent closing process using best practices. Madeline Rodriguez already had a strong closing of her calls, however, was not used to deliberately providing the thorough closings outlined by SQM. During July & August of 2021, there was a focus and contest for CSPs to go through four steps at the conclusion of each call: summarize by restating why the member called, quickly recap the work the agent did on the call, repeat any actions that were needed by either the agent or member, and then finish with saying, “Have I resolved the reason for your call today?”
As stated, Madeline already had a good closing, but agreed she could do even better by following these suggestions. Changing ones call flow can take time and effort, and it was no different for Madeline. The behaviors that Madeline exhibited in this one example are behaviors that she exhibited throughout the year and which have contributed to her excellent results. Each week the CSPs had one random call reviewed where the ending of the call was reviewed to see if those four parts were done. The agents had no idea which call would be reviewed and worked through many various scenarios to perfect the closing to ensure the member was resolved and satisfied. During the first few weeks, Madeline took feedback, sought feedback, attended calibrations, and worked on improving her call closing. As the results show, once she got her flow down, between weeks 3 and 4, Madeline never looked back.
This example shows how she goes the extra mile to improve her calls and is an indicator of the way she goes above and beyond with each of her callers to provide a World Class Call experience. She not only connects with her callers, but she also supports the call center, and helps others improve. She positively changes the way we do business at BlueCross BlueShield of North Carolina.
Madeline Rodriguez – BlueCross BlueShield of North Carolina
A Shoulder to Cry on, Even When there is No Happy Ending
“I told him that if he needed to talk, he could call and ask for me, anytime.”
Working as a CXR changes how you see the world. It can help you be better or bitter. During the initial training, we were told, “You will speak to our members at the best and the worst times of their lives.” I feel that it is my responsibility to help resolve the issues that they call about. When one of our Kansas family members calls in to add a spouse or a new baby, I will help add them to the policy. When a spouse or child calls to report the death of a loved one, I will close the account. If there is an issue with a bill, I will research and answer the questions they have; I will give them closure, even if it is not the answer they want to hear.
Occasionally, there will be a call where there is no action to take, no issue to resolve, and no happy ending. This was one such call.
When I answered the call, my caller was hostile. I immediately felt myself physically start to react - my shoulders tightened and my teeth clamped tight. My fight-or-flight instinct was kicking in. By the second sentence of our call that all had changed.
“Mr. F” was a recent widower, and he was lost. He was angry at the doctors, the nurses, the hospital, and himself. He raged at how COVID-19 had robbed him of his final kiss with his true love; how the hospital’s policies made it impossible for both him and his daughter to be with the most important woman in their life as she took her final breath. While he was crying out about her care, Mr. F was also telling me about their life. He was a tough guy from New York and she was a Kansas native. She’d challenged his perceptions, then stolen his heart, and taken his last name. Mr. F had uprooted his city life and joined her in Kansas, which then became his Camelot. He spoke of his children and his granddaughter, “C” before the grief and anger came back.
There was nothing tangible I could do for him. The claims coming in were accurate and processed on time. We went over his wife’s benefits and his financial responsibility. I asked him more about their life together, more about his granddaughter. C would tell him that Grandma was still here, and that brought a smile to his voice. That first call lasted over an hour. Before the call ended, I told him that if he needed to talk, he could call and ask for me, anytime.
A month went by before I heard from Mr. F again. This time our conversation started more gently. I could tell the anger and grief were still there, but it was not so raw. We talked about his wife’s claims, closing her policy, and her family. He was teaching C how to speak French, and his kids were helping build him a home closer to them. He talked about playing with C and how he missed his Queen. All I could do was listen.
Those conversations changed me and made me want to be a better person, a better listener, and a better customer experience representative. I will try harder not to go into a call with a perceived notion of why a caller is angry or sad. There may not be anything tangible I can do, but I can always listen, cry, empathize, and, most of all, I can be there for my Kansas family.
Jeni Harris – Blue Cross and Blue Shield of Kansas
Following Through for a Member In Need
“She was so helpful, thinking about it as a mom would. She was just so helpful and cheerful.”
Stephanie was hired in August 2019 and has exhibited excellent customer service since beginning her career at Blue Cross and Blue Shield of Kansas City. Her high drive for results ensures that she is providing members with a great customer experience. She prides herself on first-call resolution and making sure our members and her peers are very satisfied with her service.
During her time with Blue Cross and Blue Shield of Kansas City, Stephanie has worn many hats within Customer Service which have led her to her current position as a Liaison on our Support Line. One very important part of her role is to assist with the coaching and development of our Customer Advocates.
As an example of Stephanie’s high customer satisfaction percentage and her dedication to following through on a call to ensure a member’s resolution is obtained, one customer stated:
“The person I was working with was really helpful. She stayed on the phone, called me back when we got disconnected and made sure I got to the right person.”
To further evidence Stephanie’s service to our members, a member left a compliment stating:
“She was amazing to speak with. Her excellence was in working and providing me with all the information I needed. I asked as many questions as I needed. She was so helpful, thinking about it as a mom would. She was just so helpful and cheerful. I am way more educated on my insurance now, and I am really happy with Blue Cross so far. She put you guys over the edge.”
As another example, there is a member that Stephanie has helped extensively. The member was diagnosed with COVID-19 and was not doing very well. He shared with Stephanie that he almost didn’t make it. He was on a ventilator. He originally called to inquire about his inpatient hospital claim for a COVID-19-related stay. After doing some research, Stephanie let the member know she was going to send the hospital claim along with other claims she located back for reprocessing as Blue Cross and Blue Shield of Kansas City are paying 100% of the allowable for COVID-19-related hospitalizations. He was in the hospital for a lengthy stay. He was speechless and didn’t know what to say. He broke down in tears. The member was so overjoyed when he learned this because there were several claims he thought he was going to be financially burdened with. The member stated he didn’t know how they were going to do it because he had been out of work due to almost not making it out of the hospital. Stephanie continued to keep in touch with the member and provided updates on claims that continued to process due to his illness. He told Stephanie he loves Blue Cross and Blue Shield of Kansas City and our Customer Service.
Stephanie is a team player. She is always willing to volunteer for special projects or to work overtime. She is open to additional training and self-improvement tools.
She assists new hires and is instrumental in their development. These things along with the examples provided are world-class reasons to recognize Stephanie as the SQM CSR of the Year.
Stephanie Curtis – Blue Cross and Blue Shield of Kansas City
Educating members on Benefits and Healthy Lifestyle Choices
“Jill’s … ability to proactively identify the needs of our members, has truly differentiated the service experience.”
This past winter, one of our members was given some troubling news: He learned his blood sugar was elevated and that he had pre-diabetes. The 71-year-old former Marine and Vietnam veteran was motivated to take action because he has seen first-hand the havoc that diabetes can wreak on the body. He called Medicare Member Service to ask a few questions, and he had the pleasure of speaking with Jill, a Diabetes Navigator. Jill helped him understand his benefits, and then they talked about living with diabetes. Jill talked about healthy eating and exercise and how we can help him in those areas. She provided education about our reimbursement programs, and then she highlighted our on-staff dietician. Jill explained that Jane, our dietician, could help him plan healthy meals and provide some encouraging tips. After a little hesitation, and Jill’s positive reinforcement, he agreed to have a conversation with the dietician.
Before his call into Medicare Member Service, he took steps to modify his diet over the winter and spring. He stopped drinking sugary beverages, such as his nightly apple cider, and stopped putting sugar in his morning coffee. “I have not lifted one teaspoon of sugar since February,” he said. But he took the biggest strides forward this summer, after working with a registered dietitian and certified diabetes educator, Jane, as part of an innovative new Diabetes Navigator Program offered by his Medicare Advantage plan.
This newly launched health-based program provides tailored support and resources to Blue Cross Blue Shield of Massachusetts Medicare Advantage members with diabetes or pre-diabetes.
Jill’s training and experience as a Diabetes Navigator, and her ability to proactively identify the needs of our members, have truly differentiated the service experience. Jill has built strong relationships with our clinical partners, allowing her to identify and coordinate support and care needs.
“Jane has been great,” he said. “Working with her has definitely been helpful because I didn’t know what I should and shouldn’t eat and the quantities.”
“Being told you have pre-diabetes is a blessing in disguise because you have a chance to do something about it,” Jane said.
Jane worked with the member to implement small, sustainable lifestyle changes. “He has done a wonderful job making changes he can stick to,” Jane said. “His focus and determination have put him on a path to success.”
Our member learned to check nutrition labels to see how much sugar and carbohydrates he’s consuming.
He’s also become mindful of his portions. “I used to have 4-5 mandarin oranges a night, which I found out is a lot of sugar. Now I have one a night. Jane says, ‘If it fits in your hand, that’s your portion.’”
He amped up his exercise, too. “I’m very active, but I kicked it up even more,” he says, by biking, kayaking, and walking and hiking with his golden retriever, Woody.
Since the beginning of the year, he has lost six pounds, and his blood sugar numbers have decreased. He has approached this challenge the same way he’s approached other obstacles in his career – with discipline and hard work.
“I’m very serious about this,” he said. “I would encourage other people with pre-diabetes to try to take steps on their own to get their numbers down, and if they can’t do it by themselves, to reach out for help. I also would say, don’t look at the big picture. Just go at it steady and slow, and you might notice you feel better about yourself.”
The influence Jill has had on this member’s health journey goes far beyond the world-class concierge service she provided. Jill has immersed herself in learning about this complicated disease state, allowing her to provide our members with an unparalleled customer experience. Jill took the time to listen, to care, and to impact a life.
Jill Adams – Blue Cross Blue Shield of Massachusetts
What it Takes to Consistently be World Class
“The member felt she received service from Carmen that went above and beyond her expectations.”
Carmen is a multi-time World Class award winner and finalist for CSA of the year. Throughout her tenure, Carmen has known what it means, and what it takes, to be World Class. She understands that one call does not earn you World Class; it is all about building trust with your customers every day. Although she has earned World Class the past 6 years and has been a finalist multiple times, she is determined to exceed the customer’s need on each call.
The following story is an example of her taking ownership and not passing off responsibility to someone else:
One day, early in the year, during our busiest season, Carmen received a call from a member whose child was supposed to be covered on the policy, but claims were being denied. There had been some type of glitch in the file information that the member’s employer had sent to us. The denied claims resulted in large bills piling up for the member while the child was in need of more services. The parents were very worried about the bills and what else would be needed for their child. Rather than just emailing another department to have them contact the employer to sort out the issue, Carmen took ownership of the issue and helped the member with her reassuring voice. The member agreed to hold while Carmen called the employer. Carmen let the employer know there was an issue and had them send the needed information urgently. She also contacted the providers and spoke with their billing departments to explain what happened, requesting a hold on the account while everything was being taken care of to process the claims. This took the burden off the member while their daughter’s coverage was being resolved. The member felt like Carmen went above and beyond by taking ownership of the situation to get it resolved, not making them call themselves or pushing it off on another department. Not only did Carmen make the needed calls that day, but she also continued to watch the account to make sure the daughter’s coverage was updated and the claims were processed. She called the member back to confirm everything was okay with the account and claims.
Not only did she resolve the issue with the member, but she also contacted the provider to make sure that they did not have any issues on their side regarding the claims being processed. The member felt she received service from Carmen that went above and beyond her expectations.
When asking Carmen for her tips on being a great Customer Service Advocate, she states:
“If you listen to the member, patiently and compassionately, regardless of whether they are frustrated, it will build confidence in the call and will allow the member to build trust with us so that we can resolve their issues.”
Carmen Storey – BlueCross BlueShield of South Carolina
Navigating a Complex Situation for a Family in Need
“The member’s mother told Erin that she can never quit her job because she did not want anyone else working on his meds.”
Erin is a multi-time World Class award winner and understands what it means to offer world-class service on a consistent basis. She has achieved world-class certification all 4 years she has been with BlueCross BlueShield of South Carolina. She understands that one call does not earn you World Class; it involves listening to each member and showing empathy while resolving each of their concerns. Although she has earned World Class in previous years, she continues to listen to each member and provide world-class service.
One morning early last year, Erin was doing her monthly check on a member account to make sure his medications are being filled on time without issues. The member is a 16-year-old with a very rare genetic condition that requires several life-sustaining compound drugs. Erin happened to get his mother on a call in 2018 and has followed him ever since, and the mother always calls to talk to Erin. There are always changes in the dosage of his medications, as he grows; this sometimes causes an issue with prior authorizations. Since they are life-sustaining meds, they must be monitored closely. When their pharmacy went out-of-network in June 2021, Erin knew there was going to be an issue. The mother had tried several other pharmacies before, even mail order. The mail-order pharmacies either did not make the compounds, or they had shipping issues. They would not ship far enough ahead to avoid inclement weather, and the son cannot be without his medication. Erin was able to get an override for him to continue using the same pharmacy for a short time – even though it was now out-of-network for compounds – while she was looking for a new pharmacy to service his need for these important medications. While looking for another pharmacy, there were many complications with pre-authorizations. These were remedied, but the biggest factor was still finding an in-network pharmacy for his compounds. While working with Optum, Erin was able to find a compound pharmacy that was in-network for him. But, as before, there was an issue in using this pharmacy, as the pharmacy had never heard of these compounds, and the pharmacist had never made the compounds. Erin contacted the owner of the pharmacy located in Illinois; the owner was on a business trip with a lead pharmacist in California at the time. Erin was able to give the lead pharmacist and the owner the ingredients for the compound medications. While at the conference, they tracked down suppliers that could quickly ship what was needed to make the medications for the member. They called Erin back within 24 hours and agreed to make and ship our member’s medications. They also vowed to be on time, so there would be no lapse in treatment. The member’s mother told Erin that she can never quit her job because she did not want anyone else working on his meds. With the new pharmacy, it has been 5 months and there have been no pre-authorization issues, and there have been no calls for help with his medication. Erin still checks in on him and his mother to make sure that the little guy is doing okay.
When asked for her tips on being a great Customer Service Advocate, Erin stated:
“Treat each member like a family member, and listen so as to hear, not just to answer.”
Erin Jarrell – BlueCross BlueShield of South Carolina
Handling Issues from Start to Finish
“He was so thankful for Minerva handling his issue to the very end.”
Minerva is a first-time World Class award winner and understands what it means to offer world-class service. She understands that World Class is a way of life that comes with experiences that stay with us forever. Although she has been with BlueCross BlueShield of South Carolina for several years, she continues to listen to each member and provide world-class service.
One evening, Minerva received a call from a member. He had six claims that had come in as out-of-network. Minerva called the facility and the biller to confirm that they were in the network. Minerva placed numerous calls to the host plan. Once the provider’s tax ID was updated, Minerva called the provider and they submitted new claims showing they were in-network. Minerva had the out-of-network claims voided so BlueCross BlueShield could reprocess the claims, which now showed the facility was in the network. The member had a lot of patience through the long process and trusted that Minerva was handling the issue. He trusted Minerva because she called him every time she got a chance to advise that she was still working on his claims. On November 9, 2021, all his claim issues were resolved. He was so thankful for Minerva handling his issue to the very end. Her actions showed this member he can trust her and BlueCross BlueShield to advocate for him.
When asked for her tips on being a great Customer Service Advocate, Minerva stated:
“Help the member from start to finish. Show them they can trust in us.”
Minerva Robertson – BlueCross and BlueShield of South Carolina
A Customer Service Star
“The member began to cry, and asked, ‘Can you please help me?'”
Starlight is a multi-time World Class award winner. Throughout her tenure, Starlight has known what it means and what it takes to be World Class. She understands that one call does not earn you World Class; it is all about consistently advocating for your customers on every call. Although she has earned World Class in previous years, she still goes above and beyond on each call to exceed the customer’s needs.
One afternoon during the middle of the pandemic, Starlight spoke with an elderly woman whose spouse had recently passed away from COVID. The bills were beginning to come in, and she was getting a bit overwhelmed. She called Starlight, and right after Starlight greeted her, the member began to cry, and asked, “Can you please help me?” She had spoken to several different advocates about an air ambulance bill for her husband, and all she kept getting was her appeal rights. She was tired and was about to lose her home because of the ambulance bill. She went into debt to pay upfront, as ordered by the air ambulance company, because her husband was on a ventilator, and it would take too long to transport him by ground. They transported him to another hospital over four hours away. The air ambulance company gave her the itemized receipt to file a claim, and she did. The ambulance codes were not reflecting that he was transported to another hospital, in another state, four hours away, nor did the correct diagnosis, so it was denied for medical necessity.
Now, she was stuck, because she borrowed from the bank and family members, and was not getting reimbursed for the $84,000. Starlight began to think, “What if this was me?” How could she help resolve this issue for this member? Starlight could not simply tell her to file an appeal when she asked for help.
Starlight called the ambulance company, but they were no help. Starlight gathered as many related claims as she could that would show the medical necessity to include the hospital claims from both facilities. She sent all of these, as well as the benefits that stated the ambulance claims were covered both in and out of network. She explained the issue and asked management to see what could be done to at least get some of her money reimbursed because the transport was between hospitals and was COVID-related.
After a review of all the related medical documentation, Starlight finally got approval for the claim to be processed, and the day she called that member back, it felt like a gift from a child on Mother’s Day. She was crying tears of joy, and the member stated she will never forget her being the “Star” that she is.
To Starlight, being a great advocate means way more than just taking a call. It’s the happiness of knowing that the member is happy. It is the notion that what she does will create a positive lasting memory of her and BlueCross BlueShield of South Carolina.
Starlight Ervin – BlueCross and BlueShield of South Carolina
The Customer Service “Wow” Factor
“Jessica was the most helpful and caring rep I’ve spoken to in a very long time.”
Jessica is part of our Life With Blue Team where she goes above and beyond to ensure our members’ needs are met.
As one example, Jessica received a call from a member who was once a customer service representative himself. He had called in regarding a bill he had received from the facility where his son had been taken after an accident. He mentioned how many other bills he had received, but this one, in particular, showed him owing a large amount, which concerned him. Jessica not only assured the member that she would contact that facility to advise the claim was going to be adjusted due to it being an accident situation, but she also took it upon herself to contact the other providers on claims we had received for that same date span.
The member was very relieved and went on and on about how grateful he was that he was able to speak with her about this situation. He also left me a voicemail, stating:
“I would just like to commend Jessica for doing a very good job with me. I spent more than an hour with her, and I asked a lot of questions, a variety of questions. She was very patient and went the extra mile to answer all my questions, point by point. I’ve been a customer service representative and I know how it is to answer calls. I saw in Jessica the patience, determination, and the fact that she is really putting her heart into her job and going the extra mile just to answer all my concerns. Your company is very lucky to have her as one of their representatives. Thank you!”
Many members have taken the time to leave “kudos” for Jessica, stating how empathetic, friendly, and professional she has been during their interactions with her. Here are a few comments:
“I just talked to Jessica, and I wanted to let you know that she was a very helpful, and nice individual. She is a great asset to BlueCross BlueShield. Every time I call BlueCross BlueShield, I talk to such friendly representatives, but Jessica was the most helpful and caring rep I’ve spoken to in a very long time. She took the time to make calls for me, since I don’t understand insurance jargon on my bill, and was able to thoroughly explain what I would actually owe on this specific bill. I just wanted to let you know, she deserves a raise!”
“Nothing short of exceptional and professional service. She was kind, competent, very efficient, and got my questions answered in short order. She understands who the customer is, and that is why I continue to carry BlueCross BlueShield because of CAs like her. I just want her to be recognized.”
“She was tremendous, and I wanted to give her a great survey. She answered all of my questions and resolved them.”
“I didn’t get to tell a supervisor what wonderful service Jessica gave me. She is a super fantastic employee!”
“I just want to congratulate you and thank you for developing an exceptional customer service representative. I was just diagnosed with stage 4 cancer, and she went out of her way to get closure on a bill.”
“She helped me out, tremendously. She did an outstanding job on a claim that has been a couple of years old”
“In these days, there are so many stories of individuals having issues with health care providers and insurance companies that I decided I had to write to you regarding the great service I received from your employee, Jessica. I received an explanation of benefits, telling me that I received services from a non-preferred provider. I called your 800 number and was connected to Jessica. She took the time to access my records and determine that my claims were sent to a Michigan provider without the necessary paperwork. She fixed this mistake and then called the company that provided the services, established a working relationship with a representative there, and told him what was necessary for him to include in his notes so that this problem would not happen again. Wow! She also told me that I would receive another copy of the Explanation of Benefits denying another service, but that this would be taken care of via her actions today. What great service she provided to me! She is truly an outstanding individual to have working for you. She takes the time to listen, find the solution, and work to see that the problem does not happen again.”
Jessica Hathaway – BlueCross BlueShield of Texas (Federal Employee Program)
Standing with Members in Sickness and in Health
“Her engagement, care, and investment had a great impact on this member's situation and life.”
I would like to recommend Shelby Pitts for the SQM Agent of the Year award for her exceptional service and her personification of the Blue Spirit. Shelby, of course, does a wonderful job daily in her CAS role, servicing and supporting FEP members, providers, CAs, and management. She is a committed employee who delivers the highest level of service consistently, supported by her having a 100% Quality and a 90% FCR performance.
I would like to spotlight one stellar moment for recognition. I received a letter from one of our members regarding the World Class Service experience he had with Shelby. This member shared that he had experienced an accident and had to have his eye removed. In his search for an in-network oculist in Texas, he could not find one in the entire state -the nearest being three hundred miles away, in Tulsa, Oklahoma. He shared that he has contacted BlueCross BlueShield six times to confirm this and to try to determine whether it would be cost-effective to instead use an out-of-network oculist versus traveling to Tulsa for care. He was considering the distance to Tulsa, his need for five to six appointments a year, having to stay in a hotel at the beginning of the process, due to having to go two days in a row, on top of his expenses for his related surgeries. Each of the other representatives could not even give him an estimate of the out-of-pocket costs. He expressed, it was bad enough to lose an eye, but he felt that he could not get any help to navigate the situation. He noted that this was not to complain, but that he had to explain, in order to illustrate how much Shelby P. had helped him.
When he asked to speak to a team lead to see if the situation could be resolved, he was subsequently transferred to Ms. Shelby P. She "was very professional, courteous, and eager to help. She was a genuinely nice, caring individual, not just because it was her job. You could tell that this is a core personality trait." Shelby kindly offered a potential solution. "She was genuinely empathetic to my situation." Shelby took ownership of the member's situation, researching and collaborating with the coordinator to seek approval for a PPO exception, which was granted. She followed up with the member to explain the outcome and offer further guidance. She has partnered with the member to provide forward-facing support to ensure his needs have been fully met, and so that he does not have to begin again with someone new. This is great for member experience as well as business efficiency.
Although Shelby would never think of it as exceptional, her engagement, care, and investment had a great impact on this member's situation and life, saving him a lot of time and money, as his finances have taken "a hit" with all of his operations. She took the time to resolve his issue the first time she had the opportunity to connect with him.
I believe the member said it perfectly: "Ms. Shelby P is an asset to your organization, and she should be commended for her actions." When I spoke to the member, he could not emphasize enough how wonderful Shelby truly was in bringing resolution and relieving his stress.
Thank you, Shelby, for your dedication and commitment to standing with our members in sickness and in health. Thank you for all you do every day to support Federal Employee Program’s success!
Shelby Pitts – BlueCross BlueShield of Texas (Federal Employee Program)
Diligently Working to Turn a Denial into an Approval
“What I couldn’t do in weeks she did in 48 hours. I would hire her, so you need to appreciate her.”
On a Friday in June, I received a call from a member who was quite upset about a denied authorization for dental services which were needed, due to an accidental injury. The member was playing with their dog when the dog’s head came crashing into her jaw. The injury caused bruising to the member’s face which prompted her to visit her dentist. She was later referred to an endodontist.
After the endodontist’s exam, they recommended that the member have a root canal performed. The member, while not in disagreement, wanted a more permanent solution, so they were then referred to an oral surgeon. It was determined that a tooth extraction, as well as an implant, would be best, based on the circumstances. The member knew that prior authorization was required, and the office told her they would submit all the information to Blue Cross and Blue Shield of Vermont on her behalf.
When I received the call from the member, she was very upset as the request had been denied. She felt she had done her due diligence with her providers and Blue Cross and Blue Shield of Vermont and didn’t understand the denial. I reassured her that I would investigate it and confirm the next steps. I placed the caller on hold so that I could conduct additional research and then outreached to our Integrated Health team to obtain clarity on the denial. I learned that the denial was due to a lack of clinical information that Blue Cross and Blue Shield of Vermont needed to be able to make a reasonable determination. I pulled the member back on the line and explained the denial. I told her that I would outreach to the providers to get the necessary documentation to complete the review so that Blue Cross and Blue Shield of Vermont could make an informed decision.
I called the endodontist's office first, and they confirmed they had forwarded all of their information to the dentist’s office, as they were the referring provider. I made a call to the dental office and explained what was needed to conduct a review for authorization. I provided the fax number to submit all the missing clinical information and got an agreement from the office manager that they would fax the information.
I followed up with our Integrated Health team and received word that the information came in and the authorization had been approved. I called the member with the good news: not only had the request been approved, but the provider doing the work was in-network, so instead of the procedure costing her thousands of dollars out of pocket, her services would be eligible at 100% of the allowed price. The member was so relieved, she requested to speak to a manager to share a compliment:
“You have fantastic a representative in Deb, and I want to tell you why. My dog’s head hit my jaw, and my jaw was black. I got concerned, so I went to my dentist. He said you need a specialist, so I went to an endodontist. He said I needed an extraction, due to root damage, so he referred me to an oral surgeon. I went to the oral surgeon, whose front office person was very difficult to deal with. I knew it needed prior approval, and the provider’s office is telling me that they submitted everything, and I was good to go, but then I got a denial letter. I called the provider again because the denial was due to a lack of clinical. She said, ‘Oh yes, I submitted everything.’ I called Blue Cross and Blue Shield of Vermont to verify and got Deb. Deb investigated the documents submitted and found that the oral surgeon couldn’t provide the info because they weren’t the referring provider, so they couldn’t submit clinical to support the PA. Deb called the referring doctor to get clinical, it was submitted, and everything is fine now. What I couldn’t do in weeks she did in 48 hours. I would hire her, so you need to appreciate her.”
The manager shared this compliment with the call center, and said, “Well we do appreciate you Deb, and I told the caller that she couldn’t have you! Thanks for taking care of this member so efficiently and for getting done what she was struggling to do.” This made my day and was a good reminder of how taking the member out of the middle to resolve a problem may not seem like a big deal, but it certainly has a meaningful impact on our customers.
Deb Kasper – Blue Cross and Blue Shield of Vermont
Personally Invested in Resolving the Situation
“I let her know I was not going to stop trying until I felt I had done everything I possibly could.”
I remember when this call first came to me. The member was frustrated and lacked confidence that anyone was going to be able to help her. I couldn’t help but notice her tone wasn’t just filled with frustration but joined with helplessness. Trying to keep my own emotions at bay, I listened to this mother - 1,500 miles from her son – explain, through tears, how he was currently out-of-state at school, during the pandemic, away from his family, and how this had all taken a toll on his mental health. After looking online and having countless conversations with providers and insurance representatives, she found a provider who would work for her son. After multiple sessions, the provider gave the member his bill to submit to insurance. Confused about what to do, the member’s mom found herself on the phone with me. Researching this issue further, I realized this provider was not in-network, and, to further complicate the issue, the plan they were on didn’t allow the use of a network provider.
At this point, the member was lost, and I remember her saying, “None of you understand! I am hours away from my son who needs help, and I can’t help him!” I knew the member didn’t have much trust in me at this moment, but, staying confident, I told her that I am there with her and that we will resolve this together. When I said this, I remember being nervous, thinking, “How can I tell this mom, hours away from her son, that I can resolve this if I don’t know I can?” That nervousness was quickly pushed aside by confidence as I thought over all our options. One, the member can get this out-of-network authorization and her son can continue his services; that’s a win! Two, the member can’t get an out-of-network authorization, but has the option to appeal and possibly get that approved; another win! I couldn’t help but feel connected to this issue; I am also hours away from my family, and I couldn’t help but think, “What if this were me?” My mom would be on the phone constantly trying to resolve this issue, just like this mom was. I knew, even if this didn’t go the way I wanted it to, if this were me in this situation, I would want the customer service representative working on this to do everything in their power to help, letting my mom know she wasn’t alone in dealing with this. So, that’s exactly what I did.
First, after confirming with the member the importance of seeing this specific provider, I knew the only option was for the member to submit an out-of-network authorization request. The first problem we encountered was getting this out-of-network provider to help by supplying the necessary documentation. This provider chooses not to deal with insurance, so getting the information needed for the authorization wasn’t easy. After a few weeks of trying to get the provider to work with her, the member finally had enough information to submit the request. I was anxiously waiting for the member to submit it, watching the file for it to come through, and I called as soon as it came in to confirm receipt. Once the authorization was in review, I felt terrified. I have already been working with this member for weeks, and again the doubt started creeping in, “What if this doesn’t get approved?” I had to keep reminding myself that, no matter what happened, I know, and the member knows, I didn’t stop trying, and I tried my hardest for her.
Finally, there was a decision on the authorization. Reading what I thought would have been the happiest news, I was taken aback when I saw that we only approved some of the dates being requested. We allow members to submit retro authorization for services, but we can only go back 60 days from the request. I knew something extra had to be done. This member’s original call was within 60 days of the original dates she requested, but after working with the provider for so long, we fell outside of that timeframe. I called the member back, and I let her know of the approval. Before she could explain her frustration with the date range, I quickly advised that I knew this wasn’t the information she wanted to hear, and it wasn’t the information I had wanted to hear either. I knew this member’s story; I knew how much she had done just to get to this point, and most importantly, I knew if her son didn’t have the approval for all dates, he would’ve just stopped his services so that his mom wouldn’t have to worry about all of this. I couldn’t let that happen. I explained that I understood her frustration, and I understood why there was a delay. I let her know I was not going to stop trying until I felt I had done everything I possibly could.
My last hope was to reach out to our authorization team. I had to, at least, explain why the authorization was so late. The reviewing team said they would review it, but they couldn’t guarantee approval. At this point, I watched this case daily. I would check on the authorization multiple times each day. I would check back in with the member every few days, so she knew I was still here and still working for her and her son. When I came into work the next day and I checked the authorization, as I normally did, I finally saw approval for all the dates this member had been requesting. It was as if I had won the jackpot on a slot machine; I felt so excited! I knew the member’s schedule at this point, I knew she was at work and wouldn’t be home until 5 o’clock. Knowing I would have to wait for my entire workday before I could pass along this incredible news was awful! I could have left a voicemail, but I didn’t want to. The member and I had built a connection. She knew that I wanted to see these dates approve as much as she did. I knew I needed to talk to her on the phone to give her the good news.
My fingers we on the phone at 4:59, getting ready to call the member. Typically, when our authorization team approved an authorization they call the member, so as the member picked up, I asked, “Has anyone called you today?” Sounding confused, the member said, “No.” Finally, I could say the words I had been wanting to say since we started this journey together: “We approved all of your dates!” Sometimes when you feel like you have life-changing news for a member, they don’t react the way you envisioned it, but this member acted exactly how I pictured it. She asked to speak to a manager to share her experience. This was a compliment I will never forget:
“I wanted to let you know what an amazing representative you have in Nef. My son’s case is so crazy. I started working with Blue Cross and Blue Shield of Vermont last year about getting my son services. He was in rough shape, and I talked to several people who tried to guide me, but I wasn’t really getting anywhere. I started working with Nef on this at the end of September or the beginning of October. She really stepped up! I really felt that she heard me; she said that she felt it was not right, and said she would research things for me. For a family struggling to get MH counseling, her efforts made it possible for him to get the care that he needs. I am getting emotional because being a mom, 1,500 miles away from my son, was incredibly stressful for my family, and I was so worried about his wellbeing. Nef heard me, and she said, “We will figure this out together”. She really made a difference for my family. I work in customer service, and she is what a CSR should be.”
Getting the authorization approved was amazing, and knowing her son could continue his services made it even better. The feeling that came from hearing what the member had to say about me was unmatched. The only thing I want my members to remember after speaking to me is how I was there for them, and no matter how large the issue is, we will get through it together.
Nefedaya Smith – Blue Cross and Blue Shield of Vermont
Helping a Distraught Mother
“I was not going to rest until her son got what he needed to live.”
The member’s mother, Ms. Nancy, contacted us to inquire about prior authorization for her son, Justin, regarding a gastro-pace maker. The mother was very distraught over watching her son lose so much weight so drastically. I assured the mother that I would make sure she got all the help she needed for her son.
I started by reaching out to our Health Care Services (HCS) area and getting detailed information on the prior authorization. I was advised that the prior authorization was denied, due to needing additional information from the provider. The provider’s office point of contact was Tarneisha. Tarneisha advised me that updated clinical were sent and that the surgery was scheduled in a few days. I asked Tarneisha if she could schedule a peer-to-peer to help the authorization to proceed.
After the peer-to-peer was completed the following day, the authorization received a full denial as not medically necessary. The mother and Tarneisha were very upset and unsure of what to do to help Justin. I reached out to HCS for options for the member and was advised an appeal needed to be submitted. After consoling the mom, I advised her to write an appeal on behalf of her son. I spoke to Tarneisha who also submitted an appeal with all clinical and documentation for Justin. I let her know that I would be with her every step of this process to ensure she was aware of all her options. During this process, I also reached out to my management team for assistance.
The member is over 6 foot tall and originally weighed an average of 250lbs, was diagnosed with gastroparesis, and had lost over 100lbs in a month. Time was of the essence, and Justin needed a gastro-pacemaker quickly. I reached out to the mom, Ms. Nancy, and offered to forward her appeal letter to the appeals department. The appeal letter was emailed to me and forwarded to Appeals. After a nail-biting wait for determination, the denial was overturned! I reached out to Ms. Nancy to let her know the news, and we both were so emotional. In the midst of this process, I had personally just laid to rest a family member of my own, and I was not going to rest until her son got what he needed to live. I have since followed up with the member and was advised that Justin is doing great and getting back to a normal life. Ms. Nancy was so appreciative of my efforts and willingness to help.
Mary Ortiz – BlueCross BlueShield of South Carolina (BlueChoice)
A Superhero Saves a Life
“Ms. Peggy was experiencing a heart attack, and had it been left untreated, she would not have survived.”
When we think of superheroes, we might think of Spiderman, Superman, or Captain America, but what does it take to be one? According to Dale Carnegie, there are 7 characteristics that help you become a superhero: attitude, integrity, empathy, supportive, driven, courageous, and inquisitive. Anyone can be a hero, but to be super, we must act with these characteristics.
With an extensive customer service background, Angie joined our Consumers Energy family 4 years ago. As her Team Leader, I have seen her grow professionally throughout the years. In a call center, when a customer requests to speak to a supervisor, most of the time, it’s because they were unsatisfied with the service. As Angie’s Team Lead, I love taking her supervisor calls. Her customers always want someone to know how Angie treated them and how she made their life easier.
Angie defines World Class Service as:
“Some days it is sharing a laugh with our customers, celebrating their wins; other days it is shedding a tear during the tough times. But, at the end of the day, it is being in community with them, making them feel like family, and, at times, becoming family. I feel incredibly fortunate to work for a company that believes in World Class and Hometown Service. It allows me to share my beliefs of building trust, being caring, educating people, helping others, and loving all.“
We all wear different hats in our lives, but in Angie’s case, she wears her superhero cape every day. Angie is a natural. To Angie’s customers, she’s their superhero and guardian angel. She takes time to listen and build rapport.
Angie recalls one of her many customers with whom she felt a connection and need to help:
“Ms. Peggy came on my line, and I could tell she was terribly distraught, I did my best to actively listen to and discern from this what she needed, as she shared a multitude of information about her life, circumstances, and many struggles. All the while, I was caring and empathetic towards her, and patient while she was beside herself. I immediately slowed down and paid close attention, because this was much, much more than an average high-bill call. The more we talked, the more I could paint a picture in my mind: she was all alone, with no one to help her; a single elderly gal whose kids lived far away; she had no one to turn to, was in despair, and felt like she wasn’t being heard. We have all been there a time or two! I would say Ms. Peggy was lacking support from a community, and at that moment, I would become her community."
“I made a promise to look into what was happening with her account. It was a messy situation, but I was determined to help. My promise did not calm her down one bit, and she became increasingly more and more upset, sharing she could no longer talk to me because her chest was hurting from the stress. She thought she had hung up, but she did not disconnect; I could hear her pacing. I knew I needed to help her, and fast! I reached out to Security Command Central, requesting an immediate medical wellness check. They called 911, thank goodness, and an ambulance came right away. They found Ms. Peggy was experiencing a heart attack and had it been left untreated, she would not have survived. She was rushed to the hospital and underwent surgery. Ms. Peggy is alive and well! Praise God! She is practicing life with less stress, these days. I did what I hope any one of us would do.”
Angie’s heart of gold and dedication to helping others makes her not only a real-life superhero but also a valuable team member. I am extremely proud of Angie’s accomplishments, and that is why I am nominating her for the CSR of the Year for 2021.
Angela DeKlein – Consumers Energy
Good Natured Pleasantness and Cheerfulness on Display
“I don't think I've ever heard someone enjoy their job as much as she seems to.”
During my few days at the office, I couldn't help but notice Anthonette Thomas. What a lovely person!
In every call, I could hear her pleasantness and willingness to help each and every one of her customers. She really seemed to enjoy her interactions with her customers, chuckling away, and acknowledging their concerns with real human nature. I don't think I've ever heard someone enjoy their job as much as she seems to; not only in her interactions with her customers but also in her cheerfulness with her peers.
It's so refreshing to work alongside someone like Anthonette; she makes me want to do better and brings such a positive, enlightening atmosphere to those around her. In today's world, we need more kind, good-natured people like her.
To top it off, on my last day she received a commendation. What a wonderful, detailed letter from her customer addressing how helpful Anthonette was. I couldn't agree more with what he said. I'm sure you can confirm this with her TM, but I'm almost positive I’ve seen more of these on her behalf.
It's been a tough couple of years for most, and from what I see, she is among only a handful of CSRs that continue to go into the office.
Therefore, in conclusion, I would like to nominate Anthonette Thomas for CSR of the year. I hope my recommendation qualifies her for this prestigious award.
Anthonette Thomas – 407 ETR
Exemplary Attention to Detail
“This small, nearly undetectable error was causing delays in the member’s payroll.”
Nicole Lucarino joined our team in 2020, after working for the previous year in a retail banking branch. Nicole is still considered relatively new to financial services, with many of her peers boasting careers that span a decade, or several. When Nicole joined our team, she was a veteran of personalized sales and customer service roles, and it showed through her exemplary service and attention to detail.
While Nicole’s call log is filled with endless examples of her dedication to her members, there was a particularly heartwarming story with a member whom she had assisted off and on for over a year, addressing sporadic account disruptions in receiving his paycheques. On the surface, everything in our records looked accurate, so there was a lingering mystery as to why this member was having payroll disruptions. The employer told our member that the error resided with First West Credit Union. Eventually, Nicole facilitated a call with herself, our member, and the payroll department, which uncovered that the payroll team at our member’s employer had transposed some of the digits in the member’s account number in their system. This small, nearly undetectable error was causing delays in the member’s payroll landing in his account, and by facilitating the meeting, and seeing the correction through to fruition, Nicole immediately reached a permanent solution to the member’s problem.
Nicole took full ownership of this member’s concern, even following up with him on his next few payroll dates, to personally see to it that the issue was resolved. The member made a point of contacting the Advice Centre leadership team to share his profound gratitude and unwavering loyalty to the credit union as a result of Nicole’s care and commitment.
Nicole Lucarino – First West Credit Union
Showing Members that they are Valued
“Her struggle became an urgent and deep concern to me.”
As a customer service representative for Florida Blue, you never know what your day will be like. Each morning when I wake up, I do so with the intention of changing someone’s life for the better. I truly believe that treating our members in the same manner which I would like to be treated will bring value and satisfaction. I do this by listening to their concerns, maintaining current knowledge of the services we provide, and providing the members with exceptional customer service.
One morning, I received a call from Mrs. Reyes, a valued Florida Blue member for over seventeen years. She was distraught and in tears. I closely listened to her as she told me she felt that Florida Blue had turned its back on her when it came to obtaining the appropriate quantity of catheters to use, based on her Durable Medical Equipment allowance. Her doctor had written a prescription, but her current Durable Medical Equipment supplier was not fulfilling the full quantity. This left her with no choice but to begin hand-washing the catheters and reusing them. This caused her several preventable health issues, due to infections. Understandably, her struggle became an urgent and deep concern to me.
I used my current knowledge of the services her Federal Employee Program policy with Florida Blue provides, and I briefly and clearly explained these services to her. I called her current Durable Medical Equipment provider and discovered that they were not filling her script correctly, which had caused Mrs. Reyes to resort to extreme measures to sanitize the small quantity she had been given and reuse it. I canceled her current services with that provider, verified her prescription with her doctor’s office, and, through Care-Centrix, found her another Durable Medical Equipment vendor. They were able to fill her prescription correctly and provide her with the proper number of sterile catheters to use.
It has been made evident, that by listening to this member’s needs, educating her on her benefits, and then providing exceptional service, I showed Mrs. Reyes that she is a valued member of Florida Blue and conveyed that it was my pleasure to serve her. I helped to change the feelings of being ignored and unappreciated that she had before she called in. It is my mission, as well as my purpose in life, to help others, and I strive every day to make a difference in someone’s life.
In response to my interaction with Mrs. Reyes, she graciously shared her appreciation with my leadership:
“I had the pleasure of speaking to Mr. Reyes, who wanted to commend Dora for providing customer service that he and his wife had not experienced in a long time. He said that Dora truly understood the concerns and issues and that she was very professional, and went above and beyond the call of duty to resolve the issues for his wife today. In his thirty-one years of being with the insurance, you just don’t find people like Dora anymore. Mr. Reyes said that he was speechless as Dora is a wonderful human being with a golden heart and that you can tell that Dora really loves her job and cares about the members. He says that what we have in Dora is amazing, as her quality of work is inexplicable and that she is a huge asset to BCBS.”
Dora Wright – Florida Blue (Federal Employee Program)
Empathizing With a Member’s Loss
“I had tears running down my cheeks and felt my heart crush as I was hearing the story.”
“Grief is the natural by-product of love. One cannot selflessly love another person and not grieve at his suffering or eventual death. The only way to avoid the grief would be to not experience the love; and it is love that gives life its richness and meaning.” - Lance B. Wickman
When we lose a loved one, the pain we experience can feel unbearable. Understandably, grief is complicated, and we sometimes wonder if the pain will ever end. We go through a variety of emotions, such as anger, confusion, and sadness. I’m just grateful that I was the Advocate fortunate enough to answer the call from “Leo.”
Leo called to ensure that some claims previously denied for his spouse, Helen, had not been refiled or appealed by the providers. While waiting for claims to populate, I noticed the dates of service coincided with his wife’s date of death. I confirmed the claims were denied because the services were not covered by the Federal Employee Program, and we had not received an appeal on any of the claims.
Leo let out a big sigh and then proceeded to tell me the story of how Helen ended up in the hospital and, shortly after, passed away. Anger was welling up in his voice; not only did Leo blame the providers and the hospital for his wife’s death, but he blamed himself. He had decided to go home for a little while to get a bite to eat and shower, and during this time, Helen passed away, rather suddenly.
I had tears running down my cheeks and felt my heart crush as I was hearing the story. I was literally in Leo’s shoes and could empathize with him, as I, too, had recently lost someone dear to me in a very similar situation. I gained the member’s trust by listening and letting him know I understood, and he began to talk through his feelings of loneliness, anger and hurt; then there would be laughter and a military story or two as we found out we were also both Veterans. I recognized Leo was going through the Cycle of Grief while he talked. My job, at that point, was to be there to support and listen to him. His wife Helen was a Holocaust survivor as a child, when they met it was love at first sight, and she passed away just days shy of their 52nd wedding anniversary.
Through my own experience, I was able to ask Leo if he was taking care of himself, eating well, and if he had anyone close by to visit with or that could check on him, all of which he replied,” Yes.” I told him my heart went out to him, and one day he would find the courage to forgive himself because compassion and forgiveness for yourself are important in healing.
At the end of the call, Leo apologized for taking up so much of my time, but I told him, “My time is your time, and if you ever need anyone to talk to you call and ask for me.” I made sure he had my name and employee ID number, and he thanked me “for being so sweet and listening to him.”
This member interaction stands out because I made someone’s day simply by taking the time to listen and let him know someone cared. I was lucky enough to have had an experience where I was not only able to help the member, but I walked away feeling as if some weight of personal grief had been lifted off my shoulders too. This call with Leo will forever be with me and makes me proud to be a World Class Performer who is willing to go above and beyond what is expected.
Valerie Russell – Florida Blue (Federal Employee Program)
Experience Shines Through
“She strives for First Call Resolution on every call.”
Amanda ended the year 2021 with 98% Call Resolution and 80% First Call Resolution, with 41 surveys.
Amanda has been with Horizon Blue Cross Blue Shield of New Jersey for 6 ½ years, and her experience shines through! Amanda cares deeply for our members and she understands their concerns. She listens attentively and answers all questions thoroughly. She strives for First Call Resolution on every call.
Here is what some members had to say about Amanda:
“Amanda answered my question and was very clear in her communication.”
“Amanda was very knowledgeable, and the issue was resolved immediately.”
“Amanda was very professional, was competent, and was able to answer my question.”
The key to Amanda’s success as you can see from the above is her knowledge and she puts it to good use in every call. She makes all our customers, whether they are her first of the day or her last, know that she cares and is there to help.
Amanda is a valued asset to our call center and well-deserving of this honor.
Amanda Charlot – Horizon Blue Cross Blue Shield of New Jersey
Spending Time to Make a Connection
“This is the best! You explained so thoroughly, and I feel very confident.”
I started my career with Marchon/Altair Eyewear in July 2018, answering Inbound calls from our Eyecare Providers before moving into a supporting role with our Online Support team. Moving into Online Support, in September 2018, allowed me to continue my focus on providing a “World Class Experience”, now supporting our sales team and handling accounts needing assistance with our online ordering portal. There are many ways to offer support to our customers and sales team. At times there can be an issue or concern that needs immediate attention, and we get the opportunity to pull out all the stops and do what it takes to make things right for the customer.
On September 30th, 2021, I had a great call with a woman named Frances from an account in Brooklyn. Frances was transferred to Online Support because she needed additional assistance setting up her online account to use our MyMarchon portal. Frances had not done business with Marchon since 2015, so she was unsure of the registration process. I retrieved her last invoice and walked her through the entire registration process. After successfully registering Frances for MyMarchon, I helped her log in. She was very patient and receptive to my tips for making the registration process run as smoothly as possible. Once she had officially signed in, she was eager to hear more about our website, and I wanted to ensure she would have the best user experience. I walked Frances through our brands and introduced her to our sister company, Altair, since the site shows both Marchon and Altair brands in the Brands menu. I practiced placing an order together with her so I could show her the features of our shopping cart. In her words, she said it was, “very nice looking; the colors are very soft and inviting. Thank you for explaining how I can place an order on my own.”
Since this was her first time doing business with Marchon in the past few years, I gave her as much helpful information about our online ordering portal and Marchon.com as I could. At one point, I paused and apologized to her for giving her so much information, and she responded in the most wonderful way: “I love information and I appreciate this so much.” She was very happy with my knowledge and my patience while walking her through everything. In her own words, she said, “This is the best! You really explained so thoroughly, and I feel very confident that if I have to get anything I’ll know how to do it.” She truly made my day with her sweet words, compliments, and overall connection throughout the call. By the end of the conversation, she felt very confident to begin ordering with us again, and I felt proud to have re-established a relationship that resulted in a reactivated account for Marchon.
I always strive to help in any way I can, so it was very special to have that moment of appreciation from one of our accounts, and I feel that it made a difference in her wanting to continue working with us as a company.
At the end of the day, I represent the company on the front lines, and to help someone else see why Marchon is so great and how easy and wonderful it is to do business with us makes me smile. Calls like this are why I love what I do in customer service, helping people to the best of my ability. I was truly honored that Frances wanted to speak with a supervisor about the outstanding service she received from me; it was an absolute pleasure to help her.
Josephine Ferro – Marchon/Altair
Focus on Customer Delight
“She was able to turn a very dissatisfied customer into a satisfied one.”
I want to recognize Sandra Cline for all of her hard work this past year in providing World Class Service. Sandra works on a team that focuses on Customer Delight. She is tasked with being an advocate for our customers that have sent in CFPB complaints as well as escalated matters where resolution is needed. Her days are spent reaching out to our customers, providing a positive customer experience, and creating the best possible solution based on our customer’s needs.
When I hear the phrase “World Class Service”, I immediately think of Sandra Cline. Over the past year, I can think of multiple examples of when she provided World Class Service, but there is one that I just can’t forget. Sandra was assigned an account in October 2021, where a payment deferral needed to be updated and completed. Sandra worked with this customer until late last month when, where, after months of hard work, she was able to present the customer with a solution.
Sandra had lengthy weekly conversations with the customer to provide status updates and just to let her know that she was working on the issue. She sent countless follow-up emails to ensure the steps needed were being taken to ensure we got this resolved. As time passed, the customer had a few calls with the call center, where, unfortunately, the wrong information was provided. So, on the next contact, Sandra had with the customer, she was very upset with Sandra and was unsure if she should continue to work with her. This is when Sandra really shined. She explained to the customer the situation at hand and took the time to see what she could do to gain their trust back. Sandra explained that she was in the customer’s corner and was doing everything in her power to provide a resolution. At that point, the customer truly appreciated all of the hard work, but still wanted to speak with someone else about the situation. A call was made to the customer from another team member to go over the account status, as requested.
After months of ongoing emails and work behind the scenes, we were able to present a resolution to the customer. I can’t explain how happy Sandra was the day that this was resolved. She called me right away, and the first thing she said was: “I can’t wait to give the good news. The customer is going to be so happy.” Not only did the customer thank Sandra for all of her hard work, but she also brought up the time she has lost trust in Mr. Cooper and had requested to speak to someone else. She mentioned that she was sure glad that she gave Sandra the chance to get this corrected for her. Sandra advised the customer that, even though she wanted to speak with someone else, she was still going to act on all the promises she had made to ensure that we provided the best solution possible for her. The customer thanked Sandra and advised that she would make sure to stay in contact with her as she truly appreciated her.
I am so extremely proud and honored to work with Sandra. This is just one example out of many where she not only went the extra mile for a customer but where she was able to turn a very dissatisfied customer into a satisfied one. It’s amazing to go back and see how just a few conversations that Sandra has with our customers can really help create the best possible experience. Thank you, Sandra, for doing everything in your power to delight our customers, day in and day out!
Sandra Cline – Mr. Cooper
Recognized As a Service Hero
“Compassion is the wish to see others free from suffering.”
We are nominating Deleesa Williams for consideration for the SQM Agent of the Year award due to her significant contributions in 2021. She is World Class Certified with a 92%, and she received 100% CSR Csat, which speaks to the consistent world-class service she provides to each member.
In 2021, Deleesa was selected to participate in our member outreach campaigns. This story starts with a specific campaign Deleesa was working on, which involved reaching out to the member and thanking the member for choosing Blue. On one of these calls, Deleesa spoke with a member who expressed they were having a difficult time finding a mental health provider, and Deleesa quickly identified that the member needed immediate support. Due to the pandemic, finding mental health care is more difficult than ever. Nearly half of the 60 million adults and children living with mental health conditions in the United States go without any treatment. This can be for several reasons, including lack of providers, cost, or stigma surrounding this type of care.
Our member was experiencing some of the most difficult life circumstances, and Deleesa jumped into action to assist her. The member’s son had committed suicide the month prior, and she was trying to navigate the complex hospice system for her father, who was battling a terminal illness. In addition, the member was also diagnosed with bipolar depression. The member had experienced barrier after barrier with previous providers not being in-network with her new Plan, and the ones who were in-network did not have availability for many weeks.
Deleesa didn’t shy away from the challenge ahead and worked tirelessly to remove barriers for the member in order to get her the care she needed. Deleesa made outcalls to multiple providers to verify if they were accepting new patients and to identify the timeframe in which our member could be seen. After many outcalls, callbacks, and follow-ups, Deleesa found an in-network provider who was able to see our member within 10 days of the initial contact being made. Deleesa took charge of the situation, advocated for the member, and ultimately ensured that the member received the help she needed, as soon as possible.
On the follow-up call to the member, they were filled with gratitude and expressed, through happy tears, that she had a wonderful visit with her new provider of care. Deleesa showed courage and empathy in every step she took toward finding a resolution for this member. This story is amazing for many reasons: primarily, if Deleesa hadn’t made that outreach to our new member and really listened to what she needed, she may have gone without receiving the care she needed.
This member experience was nominated for a Regence Service Hero award and was chosen as a quarter 3 winner. The Service Hero Program is a company-wide recognition program. As a winner, she received a $500 check, a trophy, and a surprise visit celebrating her achievement, complete with balloons and a large cardboard check, just like you’d see in a Publishers Clearing House commercial. Her Service Hero story and the call were shared out across multiple areas. It is a highlight of the year, and these member experience stories serve as inspiration for future and current customer service professionals alike.
This example is one of many in 2021 where Deleesa anticipated all possible next steps for her customers and followed through with every promised action. Deleesa is an integral part of our team, with over 23 years of experience. She is engaging, and thoughtful, and never hesitates to offer up best practices to her peers or leaders. She primarily takes inbound calls but also participates in various member outreach activities where she is trusted to meet the member where they are and deliver valuable information to help simplify the member’s healthcare journey.
2021 SQM Comments from Members:
“I was pleased because she was very helpful. She was extremely kind, under the circumstances. She did everything that I could expect. I thought she was wonderful.”
“We're very satisfied because she helped us with everything we asked for and has followed up with us on what was happening.”
“She was very polite, knowledgeable, and efficient, and just so helpful in answering my questions and went out of her way to help resolve what my issues were.”
“She was very courteous and tried to resolve my issue. She would say yes and no and thank you, and I appreciated that.”
In closing, and reflecting on this experience Deleesa had with this member and many others, the following quote depicts Deleesa’s approach to life and service to others:
“Compassion is the wish to see others free from suffering.” - Dalai Lama
Deleesa Williams – Regence BlueCross BlueShield Plans (Federal Employee Program)
Making a Life-Changing Impact
“There are the occasions when we can really make a difference in someone’s life.”
Working at Regence is such a fulfilling and amazing opportunity. One of the many reasons involves never knowing in what way you are going to impact a member’s life. Most of the time we get phone calls about benefits, however, there are occasions when we can really make a difference in someone’s life.
Kimberly called me late one evening in August, during a health crisis. She explained to me that she had been getting in-home physical therapy in October, and they suggested that she needed a wheelchair to help her get around her apartment, at no cost. When the wheelchair came, she could not maneuver it around her home and asked for it to be taken back. The physical therapist told her to keep it because she may need it in the future.
Kimberly was very upset when she called me due to not knowing about a rental period and that, in fact, she did owe on the wheelchair that she never used. She was now being sent to collections over nonpayment of $117. I let Kimberly know that I would do my best to work with the provider to see what could be done since she was given the wrong information about rental periods, and see if they at the least could pull back from collections. I also advised Kimberly that if the provider was unwilling to assist, we could also have her file an appeal for services because she was given incorrect information.
I called the provider and explained the member’s situation and what she was advised of, and they stated there was nothing they could do. Since the member did have the wheelchair, they sent a statement to her. The member asked that I speak to a supervisor she had been working with. I called and spoke to the supervisor who said she was aware of what Kimberly was going through and what she was advised of when she received the wheelchair. The supervisor then advised that they were writing off the amount owed for July, but that Kimberly would be responsible for the rental period from October thru June. I asked if there was anything we could do to pull the amount back from collections so the member could have time to appeal or make payment arrangements. This supervisor said she would reach out to her supervisor to see if they could remove her from collections, due to extenuating circumstances.
I spoke to the supervisor again on August 24, and she advised that her supervisor would be allowing them to pull everything back from collections and that they also would be writing off the entire amount owed for the rental of the wheelchair. She advised that Kimberly would not owe anything for the wheelchair. I spoke to Kimberly on August 26 and let her know that she would no longer be responsible for the owed amounts. Kimberly was extremely thankful that I helped her by explaining everything to the provider and for the help that we were able to give her.
I was so happy that I was able to help Kimberly get that balance written off and that it was pulled out of collections. I personally know how challenging a traumatic brain injury can be, and I think this allowed me to empathize with Kimberly. I am so grateful for the opportunity to make a positive, life-changing impact on someone else’s life.
Chelsea Aynes – Regence BlueCross BlueShield Plans
Finding Resolution for a Disappointed Member
“She said that she had gone from being very disappointed in Security Health Plan to being overjoyed.”
I worked with a member who was being denied services for an injection she routinely needed for a medical condition. She had called me rather dissatisfied and puzzled as to why the injection that she normally has, and had been approved for, had not been covered this time. She wanted to know why Security Health Plan was denying the injection she very much needed. I viewed the denial on the account and reached out to our third-party vendor to discuss the reason behind the denial. I came to the conclusion that there was a recent change in the policy which caused the member's plan group number to change. I confirmed with the vendor that the member was covered by Security Health Plan for the year and that the group number had changed resulting in eligibility at the time of the submission.
I called the medical facility that had been working with the member and communicated that they were submitting the member's incorrect insurance information for the time when services were needed. They sent the request to the vendor again and included the accurate information. I called the vendor and made sure that they received the new request with accurate information in order to process it. They had received the information that they needed and were able to approve the member for the injection.
I called the member back and advised that we had everything sorted out. I kept her aware of what I was doing to help her. She said that she had gone from being very disappointed in Security Health Plan to being overjoyed that someone took the time to help her get to the bottom of the denial and to solve the matter. She said she had placed the blame on Security Health Plan, when, in fact, it had been on the medical facility’s end for not submitting correct information on her behalf. She was overjoyed that the matter was all sorted out and that she could continue with her injections. This is a story that I will always remember, as I was able to connect with the member and help solve the tough situation that she was in.
Julie Bolen has been with Security Health Plan since November 2018. During that time, she has proven to be an integral part of our Customer Service team. She quickly became trained on all of our core product lines and has been a great resource for our new agents. Julie has one of the highest-quality audit scores in the department, averaging 98% for 2021. Julie was also recognized for being on our Wall of Fame, with perfect audit scores for the month, numerous times in 2021. Due to Julie’s outstanding quality and knowledge, being trained on all product lines, she was promoted to a Benefits Specialist Agent in 2021.
Julie also assists with some extra duties, on top of taking member calls. She recently learned about our chat channel and has been receiving great member feedback. She also assists with doing outbound grace period calls for our members who have missed or are late on their premium payments. Julie is a very well-rounded agent – not only is her quality astounding, but she comes in every day and works hard, and is a great team player. She has very minimal away-from-desk time, and her project time is one of the lowest in our department. She is always going back on ready right away to be able to assist as many members as she can, all while giving them outstanding service and a great member experience. You can hear in her voice that she is there to help and truly cares for our members. Julie is well above our department average for calls taken. She answered 6387 calls last year, while the department average was 4093.
Her SQM feedback was something to be proud of in 2021. Her Call Resolution increased from 93% in 2020 to 100% in 2021! Her FCR increased from 88% in 2020 to 93% in 2021, and her World Class increased from 92% in 2020 to 98% in 2021! She had amazing results this past year, and we are so proud to have her as part of our Customer Service team here at Security Health Plan. Julie is the most humble person you will ever meet and quietly comes in every day to do her job. The aforementioned stats showcase how remarkable she really is.
Julie Bolen – Security Health Plan
Outstanding Feedback from Peers, Supervisors, and Callers
“I feel very empowered about what decisions I am going to make down the road, and this is all due to Michael."
Michael joined VSP in November 2020. In 2021, he demonstrated his desire to provide a great member experience which resulted in Michael receiving all World Class Surveys. Michael strives for excellence and makes VoC a priority in his 1:1 meetings.
Feedback shared from Michael’s peers:
Michael interacts with the team in the chats and is willing to assist anyone, as time permits. He will respond in the chat if someone needs help, and he is available to assist them with their call. I would consider Michael a great team player and he is always congratulating others, as well. Even though Michael moved over to the EEO department for about three months, he never strayed away from the team. He remained in contact with us when needed and stayed engaged with his colleagues in the chat.
Michael keeps us engaged with each other by posting food, thoughts, and encouragement in the chats. If one of us is not feeling well, he shows genuine concern and reaches out to make sure we are okay.
Feedback shared from Michael's Supervisor:
Michael recently moved to EEO in November and has been doing an amazing job. I received great feedback from his Supervisor in EEO, commenting that he is very clear, concise, and committed to doing the job correctly. Michael was very excited to receive this position and is always open to learning new things and applying for more positions. He would like to grow with the company and expresses his interests every chance he gets to learn something new. He started his own growth and development plan and keeps me honest on following up with him to make sure he stays on track.
Michael goes above and beyond on his calls by making sure he understands the reason for the call, asking probing questions, building a connection, and confirming issue resolution. He is committed to taking care of the caller, follows up with them, and reaches out for assistance.
Michael shows constant commitment to his performance. He consistently checks the SQM website to see what surveys he received and will let me know when he has received another World Class Survey.
I would say Michael embodies a committed, trustworthy, and caring employee. Whether it is caring for his peers or the callers, he always gives his best effort each day that he shows up to work. He often expresses how he loves VSP as a company and will continue to do his best in servicing the callers.
Michael received 7 proud letters last year. Here are a couple of comments from proud letters he received:
“Michael is so amazing. He went above and beyond to get my situation taken care of. I had an odd enrollment situation, but he took the time to listen to my needs and figure out a solution. He was so kind and so thorough. Thank you for all your help, Michael!”
“I just got off the phone with Michael Miles, and I wanted to take the time out to give some feedback on him. We spoke for about 20 minutes, or so, and he was fantastic. The guy was patient and thorough, and he spoke to me in layman’s terms when I asked him questions about different benefits. He was able to answer every question I had. He was outstanding and has great customer service skills. I feel very empowered about what decisions I am going to make down the road, and this is all due to Michael."
These comments are just a small reflection on how Michael helps and assists his callers, demonstrating that he cares.
Michael Miles – VSP Vision Care