Medicare Advantage Prior Authorization Redesign

  • Delivered on time for critical MA product launch
  • Implemented AI to accelerate research under constraints
  • 96% drop-off → 80%+ usability improvement
  • Lightning Jam workshops aligned teams in 1-2 hours
  • Led shift from paper/PDF to digital-first workflows
Overview

In 2024, I led the prior authorization redesign for a company-wide Medicare Advantage (MA) product launch - a high-stakes, deadline-driven initiative with strict CMS regulatory requirements. Facing aggressive timelines and limited access to traditional user research, I used AI-driven research methods and Lightning Jam workshops to deliver a digital-first experience that improved usability by 80%+ over the existing 96% drop-off rate.

We delivered on time, supporting a critical business milestone while establishing scalable UX processes and initiating a shift away from paper/PDF-based workflows.

  • CompanyBlue Cross and Blue Shield of Nebraska
  • IndustryHealthcare Insurance
  • RoleLead UX Designer, Research, Analytics, Cross-Functional Leadership
  • Timeline2024 - 2025
  • StatusLaunched, adopted, updates in progress

ACT 1: The Challenge

The Business Problem

Our company was launching Medicare Advantage (MA) products for the first time - a major strategic initiative with strict CMS regulatory requirements and aggressive deadlines. The prior authorization process was mission-critical but had been designed for commercial insurance products, not MA's unique requirements and user base.

The existing process:

  • 96% drop-off rate - members abandoned prior authorization requests
  • Paper/PDF-based workflow - statuses were printed and mailed, creating delays
  • No digital-first experience - members couldn't manage prior authorizations online
  • Commercial product assumptions - didn't account for MA member needs or CMS guidelines
The User Problem

Members faced:

  • Confusing prior authorization statuses (partially denied, pending, approved)
  • No clear action steps when something was denied or needed follow-up
  • Waiting for mailed documents instead of real-time digital updates
  • Calling customer service representatives for help understanding next steps

"Members with the most complex healthcare needs - those requiring prior authorizations - were getting the worst digital experience."

The Constraints

Timeline pressure: Company-wide MA launch with fixed, non-negotiable deadline

Limited research access:

  • No existing MA members to test with (new product)
  • Initial research based on commercial product feedback
  • Business prioritized speed: "ship fast" was the mandate

Regulatory complexity: CMS guidelines required specific information, disclosures, and processes

Limited UX maturity: Testing and measurement weren't built into the aggressive timeline

"I needed to deliver user-centered design for a critical business launch without the luxury of traditional research cycles or lengthy discovery phases."

ACT 2: The Journey

My Role & The Team

As Principal UX Designer I was Responsible for:

  • Prior authorization experience redesign for MA members
  • AI-driven research and content strategy
  • Wireframing and prototyping
  • Lightning Jam workshop facilitation
  • Design system components for implementation
  • Cross-functional collaboration and stakeholder alignment

The Team: Part of a larger MA member portal initiative with multiple parallel workstreams including product owners, developers, customer service, compliance, and business stakeholders.

Chapter 1: Innovation Under Constraints - AI-Driven Research

"Without time for traditional user research, I needed to innovate. AI became my research accelerator."

The AI Strategy: tools I used strategically:

  1. Custom Healthcare AI Agent - Built a specialized copilot trained on:
    • MA and healthcare domain knowledge
    • CMS guidelines and regulatory requirements
    • Existing print templates and trusted sources
    • Customer service call patterns and resolution workflows
  2. UXPilot
    • Rapid wireframe generation and iteration
    • Quick concept visualization
    • Design exploration at speed
  3. Claude (Anthropic)
    • Content development and scenario analysis
    • Journey mapping and pattern identification
    • Regulatory language refinement

Why AI?

  • No existing MA members - New product meant no user base to test with
  • Aggressive timeline - Traditional research cycles would miss deadline
  • Need for domain expertise - Required deep understanding of CMS requirements quickly
  • Customer service insights - Needed to understand how reps handled these calls in practice

"Without time for traditional user research, I needed to innovate. AI became my research accelerator."

What AI Research Revealed

  • Different prior auth statuses required different guidance (partially denied ≠ pending)
  • Phone support was working because reps walked members through actions
  • Pre-filled context (what medication, what doctor) reduced confusion
  • Members wanted multiple resolution paths (call, message, upload documents)
Chapter 2: Lightning Jam Workshop - Rapid Stakeholder Alignment

"I needed cross-functional buy-in fast. Lightning Jam methodology - compressed UX workshops - proved perfect for enterprise speed."

The Workshop Approach

Lightning Jam format (adapted from industry best practices):

  • 1-2 hour time-boxed sessions (not multi-day workshops)
  • Cross-functional participation (product, development, customer service, compliance)
  • Focused outcomes (pain points, prioritization, alignment)

Workshop Participants:

  • Product owners and managers
  • Business stakeholders
  • Customer service representatives (critical - they knew member pain)
  • Development team leads
  • Compliance/regulatory experts

Outcomes:

Pain points identified:

  • Members don't understand prior auth status language
  • No guidance on what to do when something is denied
  • Waiting for mail creates anxiety and delays care
  • Calling customer service is only option (creates call volume)

Prioritization:

  • Must-have: Status-based guidance, clear action steps, digital-first workflow
  • Should-have: Multiple contact methods, document upload
  • Nice-to-have: Historical tracking, prescription details

Alignment achieved:

  • Cross-functional agreement on "digital-first" approach
  • Buy-in for AI-supported research methodology
  • Shared understanding of CMS requirements vs. user needs
  • Development team commitment to timeline

"In 1-2 hours, we went from scattered opinions to aligned strategy. Lightning Jams proved that efficient workshops can work at enterprise scale."

Chapter 3: The Design Solution - Status-Based Step-by-Step Guidance

"The insight was simple: translate the helpful customer service rep conversation into a digital experience."

Core Design Principles

  1. Mimic the Helpful Rep
    • AI agent analyzed example customer service call flows
    • Translated phone support patterns into digital guidance
    • Used plain language, not insurance or medical jargon
    • Walked members through actions step-by-step
  2. Status-Driven Experiences
    Each prior authorization status triggered specific, contextual guidance:
    • Partially Denied:
      • "Here's what was approved and what wasn't"
      • "Here's why [specific reason]"
      • "Here's what you can do: [action steps]"
      • Pre-filled: medication name, doctor info, denial reason
    • Pending Additional Information:
      • "We need [specific info] from your doctor"
      • "Here's how to request it: [action steps]"
      • Pre-filled: what's needed, which doctor, how to contact
    • Approved:
      • "You're all set - your [medication/procedure] is covered"
      • "Here's your coverage details"
      • "Here's what happens next"
    • Denied:
      • "Your request wasn't approved. Here's why."
      • "You have options: [appeal process, alternatives]"
      • Clear next steps with multiple paths forward
  1. Pre-Filled Context with Clear Actions
    • For each status, showed:
      • What: Specific medication or procedure name
      • Who: Doctor or provider involved
      • Why: Clear reason for status (in plain language)
      • Next action: Specific steps member could take
    • Action examples:
      • "Call your doctor at [pre-filled number]"
      • "Message our team with questions"
      • "Upload requested documents here"
      • "Start an appeal process"
  2. Digital-First Workflow
    • Instead of printing and mailing status updates:
      • Real-time status in member portal
      • Multiple resolution paths (call, secure message, document upload)
      • Proactive notifications when action needed
      • Mobile-responsive for on-the-go access

"I designed the digital equivalent of a helpful customer service rep sitting next to the member, walking them through exactly what to do next."

Examples of the wireframe and a more realistic view for both experiences
Chapter 4: Designing for MA and Commercial Products
The prior authorization redesign needed to work for two different products:

Medicare Advantage (MA):

  • Older user base with different needs
  • CMS-specific regulatory requirements
  • Required specific disclosures and language
  • New product - no historical data

Commercial Insurance:

  • Existing product and user base
  • Different regulatory requirements
  • Broader age range
  • Established workflows and expectations

Solution: Flexible Design System

Created component-based design that supported:

  • Shared framework: Status-based guidance structure worked for both
  • Content variations: CMS-compliant language for MA, standard for Commercial
  • Regulatory flexibility: Easy to add required disclosures per product
  • Scalable approach: Future products can use same system

"The underlying UX pattern - status-based step-by-step guidance - was universal. Only the specific content and regulatory requirements varied by product."

Examples of going from CMS Guidelines to Customer Service Action Experience
Chapter 5: Prototype Validation

"While we couldn't conduct traditional user testing with MA members, we validated the approach internally."

Testing Approach:

  • Internal stakeholder testing with realistic scenarios
  • Customer service representative walkthroughs (they knew member pain points)
  • Cross-functional review ensuring technical and regulatory feasibility
  • Accessibility review for ADA compliance

Results:

Initial state: 96% drop-off in prior authorization completion

Prototype validation: 80%+ improvement in:

  • Task completion rates (members could find and understand next steps)
  • Perceived usability (step-by-step guidance made sense)
  • Confidence in actions (members knew what to do)

Key feedback:

Created component-based design that supported:

  • Step-by-step guidance significantly reduced confusion
  • Pre-filled context eliminated guesswork about what was being authorized
  • Multiple resolution paths gave members control over how to proceed
  • Plain language made complex insurance concepts understandable

"The 80%+ improvement validated that translating helpful phone support into digital self-service was the right approach."

ACT 3: The Outcome

"We delivered on time for the company-wide Medicare Advantage launch - a critical business milestone."

01.

What We Shipped:
  • Complete prior authorization redesign (MA and Commercial)
  • Status-based step-by-step guidance framework
  • Digital-first workflow replacing paper/PDF process
  • CMS-compliant design system components
  • Successful handoff to implementation team

02.

Business Impact:
  • Delivered on schedule for high-stakes MA product launch
  • Supported critical business milestone enabling company to enter MA market
  • Established scalable framework reusable for other MA portal features
  • Cross-product solution serving both MA and Commercial members
  • Digital transformation initiated shift from paper/PDF workflows

03.

Design Impact (Prototype Validation)
  • 96% drop-off → 80%+ improvement in task completion and perceived usability
  • Step-by-step guidance significantly improved member confidence in next actions
  • Multiple resolution paths gave members control (call, message, upload)
  • Pre-filled data reduced cognitive load and confusion
  • Plain language made complex insurance concepts understandable
Strategic Wins

AI-Driven Research Methodology:

  • Proved AI can accelerate UX research when timelines are tight
  • Created replicable approach for future deadline-driven projects
  • Generated actionable insights without lengthy traditional research cycles
  • Custom healthcare agent provided domain expertise at speed

Process Innovation:

  • Lightning Jam workshops aligned cross-functional teams in 1-2 hours (not days/weeks)
  • Demonstrated UX value in fast-moving, deadline-driven environment
  • Established efficient collaboration patterns for future MA initiatives
  • Got stakeholder buy-in through focused, time-boxed collaboration

Digital-First Transformation:

  • Led shift away from paper/PDF mailed workflows
  • Created member self-service paths reducing phone support dependency
  • Established patterns for future digital-first experiences
  • Improved member access to real-time information

Regulatory Navigation:

  • Successfully designed for CMS compliance requirements
  • Created flexible framework supporting different regulatory needs
  • Balanced user experience with mandatory disclosures
  • Established approach for future regulated product features
Reflection

Innovation Through Speed

"This project proved that rigorous UX thinking and rapid delivery aren't mutually exclusive. When traditional research timelines don't align with business needs, strategic use of AI tools and compressed collaboration methods can still deliver strong outcomes."

What Worked

01.

AI as
Research Accelerator:
  • Custom healthcare agent trained on CMS guidelines, customer service patterns, and trusted sources
  • UXPilot.ai for rapid wireframe iteration
  • Claude & MagicPatterns for content strategy and scenario modeling
  • Generated insights in days that would typically take weeks

02.

Lightning Jam
Methodology:
  • Time-boxed workshops (1-2 hours) got stakeholder alignment quickly
  • Cross-functional participation ensured feasibility and buy-in
  • Prioritization frameworks focused effort on highest-impact features
  • Efficient collaboration that respected everyone's time

03.

Status-Based
Guidance Approach:
  • Translated customer service call patterns into digital experiences
  • Matched helpful phone support in self-service format
  • Reduced member confusion and increased perceived usability by 80%+
  • Created reusable pattern for other complex member tasks

04.

Digital-First
Mindset:
  • Led transformation from paper/PDF to real-time digital
  • Created multiple resolution paths (not just phone support)
  • Improved member access to information when they needed it
Working at Enterprise Speed

This project reflects the reality of enterprise product launches:

Aggressive timelines driven by market and regulatory pressures

  • Company-wide MA launch had fixed deadline
  • Multiple parallel workstreams requiring coordination
  • "Ship on time" was non-negotiable business requirement

Cross-functional coordination at scale

  • Product, development, compliance, customer service, business stakeholders
  • Regulatory requirements (CMS) balanced with user needs
  • Technical implementation coordinated with multiple teams

Practical tradeoffs

  • Traditional user research with MA members wasn't possible (no existing users, tight timeline)
  • Post-launch measurement not scoped into initial project
  • AI-driven research and internal validation had to suffice

The validation:

  • 80%+ improvement in prototype testing showed the approach worked
  • Successful on-time delivery supported a critical business milestone
  • Framework is reusable for future MA features
  • Digital-first transformation initiated lasting change

"I would have loved to conduct traditional user research with real MA members and measure post-launch metrics. But the business needed a solution delivered on schedule for the MA launch, and we succeeded in delivering it."

What I'm Proud Of
Delivered business-critical work under pressure

MA launch succeeded on schedule

Innovated research methodology

proved AI can strategically accelerate UX when used thoughtfully

Created lasting impact

digital-first framework and reusable design patterns

Led efficient collaboration

Lightning Jams aligned teams in hours, not weeks

Solved real member problems

96% drop-off → 80%+ improvement is significant

Navigated complexity

balanced user needs, CMS regulations, and business constraints

What This Taught Me
01.AI tools are powerful when used strategically:
  • Not a replacement for user research, but an accelerator when timelines are tight
  • Custom agents trained on domain knowledge can surface insights quickly
  • Rapid prototyping with AI extends designer capacity
  • Still requires UX expertise to interpret and apply insights
02.Process innovation matters as much as design innovation:
  • Lightning Jams proved efficient workshops can work at enterprise scale
  • Getting stakeholder buy-in quickly is a skill that complements design craft
  • Time-boxed collaboration respects everyone's schedule while driving results
  • Sometimes constraints (tight timeline) force better, more focused processes
03.Enterprise work requires flexibility:
  • Ideal conditions (lengthy research, post-launch measurement) aren't always possible
  • Delivering strong work under real-world constraints is a valuable skill
  • Business impact (on-time delivery for MA launch) sometimes takes priority
  • Understanding when to adapt methodology vs. when to advocate for best practices
04.I look for organizations that:
  • Value speed AND quality (not just "ship fast and forget")
  • Invest in measurement and iteration (build learning into project scope)
  • Support UX research even under tight timelines (allocate time for validation)
  • Build post-launch tracking and refinement into roadmaps
  • Balance business urgency with commitment to user-centered design

"This project showed me I can deliver under extreme pressure while still maintaining UX rigor. But I also learned to look for environments where post-launch learning and iteration are built into the culture, not treated as optional."