Achieving a complete, 360-degree view of member eligibility is often challenging due to fragmented data sources and reliance on manual, email-based workflows. Current processes frequently involve static Excel or CSV files exchanged with external vendors — a method that is time-consuming, error-prone, and lacking real-time oversight.
Business analysts and eligibility teams face the absence of a unified interface to efficiently access, validate, and update member eligibility data. These disconnected processes lead to higher operational overhead, slower turnaround times, and an increased risk of inaccuracies.
To address these challenges, we developed an Agentic AI-powered Eligibility Update Automation solution. Leveraging Azure OpenAI, Azure Logic Apps, Azure Cognitive Services, and Semantic Kernel, the multi-agent architecture automates email monitoring, data extraction, validation, classification, bulk updates, and service request synchronization. This enables accurate, real-time eligibility updates — eliminating manual intervention while improving efficiency and accuracy.
Problem Statement
In a typical customer service workflow for member eligibility management, processes are heavily manual and prone to delays. Internal eligibility teams compile member details and share them with external vendors via email using Excel or CSV files.
Vendors review and update these files with eligibility decisions — such as approved or denied — addressing scenarios like account creation and onboarding. Once returned, the internal team manually or through bulk upload updates the core application, followed by updates to corresponding service requests in the ticketing system.
This email-driven, multi-step workflow suffers from:
- Lack of automation
- Limited auditability
- No real-time visibility
The result? Longer turnaround times, higher operational costs, and an increased risk of data errors.
SNP’s Solution Overview
Our AI-driven, agent-based solution is designed to eliminate manual effort, streamline communication, and ensure accurate, scalable processing of eligibility updates.
Key capabilities within the Agentic Framework include:
- Email Monitoring – Automatically scans incoming vendor emails, extracts relevant attachments (Excel/CSV), and routes them for processing.
- Data Extraction & Validation – Reads and validates member updates for completeness, accuracy, and consistency, flagging anomalies.
- Scenario Classification – Uses AI models and business logic to categorize updates (e.g., Approvals, Denials, Account Creation, Onboarding).
- Bulk Update Preparation – Transforms validated data into application-ready formats for seamless uploads into core systems.
- Service Request Update – Synchronizes updates in the ticketing system to maintain operational alignment.
- Exception Management – Isolates incomplete or erroneous records for manual review, safeguarding data integrity.
A real-time Operations Dashboard provides insights into key process metrics — including processed email counts, updated member records, pending exceptions, SLA adherence, and turnaround times.
System Architecture
Master Agent
Serves as the central coordinator, maintaining context and orchestrating downstream agents. Built using Azure OpenAI and Semantic Kernel for intelligent task handling.
Email Monitoring Agent
Continuously scans inboxes, extracts vendor attachments, and securely passes files to downstream processes.
Validation & Classification Agent
Ensures data accuracy, validates completeness, and classifies records using AI models and business rules.
Bulk Update Agent
Formats validated records for automated integration into core systems like Mydas.
Service Request Update Agent
Updates related service requests in ticketing systems such as Remedy Force, ensuring synchronization.
Exception Management Agent
Flags problematic records, creates review queues, and facilitates manual intervention.
Deployment and User Experience
Our solution integrates seamlessly with existing customer service environments through secure enterprise interfaces. Built entirely on Azure services, it delivers compliance, scalability, and strong data governance.
Eligibility analysts benefit from:
- An intuitive interface that eliminates manual email handling.
- Automated workflows that free up time for higher-value tasks.
- Real-time dashboards for complete process visibility.
Key Business Benefits
- Enhanced Operational Efficiency – Automation reduces processing time and manual workload.
- Improved Data Accuracy – Structured validation prevents human errors.
- Real-Time Transparency – Dashboards and audit trails support SLA compliance.
- Scalable & Modular Design – Easily extendable to new workflows and systems.
Reference Workflow
Conclusion
Transitioning from manual, email-driven eligibility workflows to an AI-driven, multi-agent architecture marks a significant step toward operational excellence. By combining intelligent automation, scenario-based classification, and seamless system integration, organizations can achieve faster turnaround times, improved data integrity, and enhanced process visibility.
This solution empowers eligibility teams to focus on strategic, high-value initiatives while ensuring accurate, compliant, and timely updates — ultimately elevating service quality and business agility.
