Customer 360 Guide for

Healthcare Payers
Salesforce, Spring ’24

@salesforcedocs
Last updated: December 29, 2023
© Copyright 2000–2024 Salesforce, Inc. All rights reserved. Salesforce is a registered trademark of Salesforce, Inc., as are other

names and marks. Other marks appearing herein may be trademarks of their respective owners.
CUSTOMER 360 GUIDE FOR HEALTHCARE PAYERS

Create human-centered experiences across all health and life science touchpoints.
The assets in this Customer 360 Guide help healthcare payers build a vision and make a plan for digital transformation. Learn with
Trailhead
Architectural diagrams and business scenarios show you how Salesforce products combine with industry best practices to expand your
business capabilities. Solution Kits show you how to implement Salesforce-recommended cross-cloud solutions to common retail use
cases.

Industry Blueprint for Healthcare Payers

Examine the Salesforce view of strategy, product innovation, and partner relationships to enable front-end and back-end business
processes in the healthcare payer business.
Reference Architecture for Healthcare Payers
Map specific Salesforce products to the functional capabilities and operational activities of healthcare payer organizations.
Business Scenarios for Healthcare Payers
Business scenarios help you bridge the gap between your organization’s business capabilities and the solutions that can set your
organization on a course to achieve its goals. For each scenario, discover a variety of Salesforce solutions that can reduce your time
to value and help define a roadmap to build out your organization’s functionality.
Solution Architecture for Healthcare Payers
Identify the specific tools and resources that can help you deliver comprehensive automation solutions for healthcare payer
organizations.
Explore Solution Kits for Healthcare Payer Organizations
Enhance your cross-cloud business by implementing one or more solution kits. Get product recommendations, workflow details,
and instructions to help you implement the solution from start to finish.

SEE ALSO:
Customer 360 Guide for Healthcare Payers Learning Map

Industry Blueprint for Healthcare Payers

Examine the Salesforce view of strategy, product innovation, and partner relationships to enable front-end and back-end business
processes in the healthcare payer business.
The industry blueprint is a type of reference architecture that describes the end-to-end customer lifecycle. Use the industry blueprint to
understand how Salesforce Customer 360 platform capabilities help structure, organize, and support digital transformation.
• Map customer-facing business capabilities that are common to healthcare payer stages. Include the customer lifecycle across
marketing, sales, customer onboarding, origination, and fulfillment, through to servicing and the post-sales experience.
• Determine which capabilities are most important to your organization and prioritize implementation accordingly.
• Organize projects that deliver business value with maximum benefit.
• Gain alignment among key business process stakeholders.
• Understand the high-level platform capabilities and the Salesforce partners that power your organization’s business needs.

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Customer 360 Guide for Healthcare Payers Industry Blueprint for Healthcare Payers

Contact your Salesforce account team or a Salesforce partner for help with assessing the business and platform capabilities most suited
for your organization.

The typical lifecycle of a customer relationship in the Payer Healthcare industry can be organized into seven major business processes.
Each major process is made up of four subprocesses that together fulfill a business need for one stage of the cycle.
1. Marketing and Sales involves lead generation, individual and group sales, and broker relations.
2. Enrollment and Administration includes member and group enrollment as well as account installation, and reporting.
3. Member Service covers all aspects of member engagement from inquiries, appeals, and grievances to coaching and wellness.
4. Medical Management relates to the care of individuals. It looks at population health, medication management, and even healthcare.
5. Network Management covers the aspects of provider onboarding and services.
6. Benefits and Products include the strategy, planning, and lifecycle management of healthcare-related products.
7. Employee Engagement encompasses the training, onboarding, collaboration, and human resource disciplines for a company.
Salesforce partners with independent software vendors (ISVs) and consultants to extend platform capabilities that suit business processes.
Other industry-specific integrations and complete solutions are important in a typical business context. To learn more about ready-to-install
applications, solutions, or consultants, check out AppExchange.

Note: To understand which business capabilities, solutions, and Salesforce products can help your organization achieve the
business needs identified on the blueprint, review the Business Scenarios for Healthcare Payers on page 5.
Platform Enablers, API, and Data Sources are common across all lifecycle stages and business processes. Use platform enablers, APIs, and
data sources as a baseline of functionality to support tailored solutions.

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Customer 360 Guide for Healthcare Payers Reference Architecture for Healthcare Payers

Note: To understand how industry and business requirements link to the underlying technologies that support them, review the
Reference Architecture for Healthcare Payers. Use the industry blueprint as a framework for creating a reference architecture for
planning customer experience enhancements.

SEE ALSO:
Industry Blueprints for Partners
Salesforce Architectural Diagrams: Quick Look
Salesforce Architectural Diagrams: Quick Look

Reference Architecture for Healthcare Payers

Map specific Salesforce products to the functional capabilities and operational activities of healthcare payer organizations.
Salesforce provides configurable product solutions that support a healthcare payer’s ability to effectively engage their customers and
partners. The reference architecture helps communicate the vision and strategy of a solution to business executives and stakeholders.
Learn with Trailhead.
Our reference architecture presents Functional and Platform capabilities. Each layer contains a representative subset of systems or
capabilities that are most relevant for consumer goods organizations. It doesn’t list all possible systems or capabilities.

Platform Capabilities
These components form the underlying technology base for achieving your goals. Each layer in the platform builds on top of the next.
B2B systems typically rely on these elements.

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Customer 360 Guide for Healthcare Payers Reference Architecture for Healthcare Payers

Data Sources
Data sources are systems that create, collect, and manage various types of data. These systems can act as systems of record. They’re
often purpose-built to handle particular functionality and data requirements, but some provide general system needs.
Integrations
Integrations include tools and routes that connect systems of record with each other or with higher-level experiences. Integrations
can include varied tools like APIs that connect separate systems, single sign-on services to manage customer identity across different
systems, and customer data platforms that segment customers.
Intelligence
Smart automation like machine learning and AI helps you optimize your use of customer data. To enhance your customer relationships
and drive sales, the intelligence layer serves functions like delivering actionable customer insights, personalized product
recommendations, and improving real-time customer interactions.
Analytics
Analytics helps you better understand your data and make smart business decisions.
• Descriptive analytics summarize existing data to help you better understand the current state or past activities. Descriptive
analytics typically answer “What?” questions about your data.
• Diagnostic analytics use the output of descriptive analytics to identify patterns and outlier data. Diagnostic analytics typically
answer “Why?” questions about your data.
• Predictive analytics use historical data to anticipate future outcomes, such as the likelihood that a subscriber opens an email.
• Prescriptive analytics suggest courses of action based on your existing data. Prescriptive analytics typically answer “Should?”
questions about your future actions.
Platform Enablers
Use common capabilities that drive the business processes across the enterprise. Build a unified profile using a customer data
platform. Drive workflows and engagement based on that unified profile.

Functional Capabilities
Business-specific elements at the functional capabilities level are connected more directly to the customer’s experience and measured
in terms of maturity. Successful implementation of functional capabilities depends heavily on implementation of the platform capabilities.
The member lifecycle typically crosses multiple engagement channels in the areas of marketing, sales, support, care programs, self-service,
and commerce. In addition to customer service, payers provide a continuum of care for their members. Improving the overall experience
from service to personalized care is essential for payers to retain and delight their members. There has been an industry shift to creating
a holistic view of each member in order to provide the most relevant and timely information for agents, as well as reduce costs through
efficient integration and data alignment.
To identify strategic goals around which to focus your implementation,review these commonly required functional capabilities to identify
strategic goals around which to focus your implementation.
A Business Capability Maturity Assessment arranged by your Success Manager or Account Executive can help you determine which areas
of your business can benefit from more focus.

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Customer 360 Guide for Healthcare Payers Business Scenarios for Healthcare Payers

Mapping Platform Capabilities to Salesforce

Specific Salesforce products handle each of the needs identified at the platform capability level.
Identify gaps in your underlying capabilities by customizing this model to include other Salesforce products or third-party systems in
your current technology stack.
To explore the reference architecture specific to your business, contact your Success Manager or Account Team.

Tip: Business Scenarios for Healthcare Payers on page 5 help you better understand your business capabilities and find solutions
that support your business goals.

SEE ALSO:
Salesforce Architectural Diagrams: Quick Look

Business Scenarios for Healthcare Payers

Business scenarios help you bridge the gap between your organization’s business capabilities and the solutions that can set your
organization on a course to achieve its goals. For each scenario, discover a variety of Salesforce solutions that can reduce your time to
value and help define a roadmap to build out your organization’s functionality.

Get the Most Out of Business Scenarios

Following best practices and selecting the right solutions and products are key to a successful implementation of business scenarios.
Follow these steps to use business scenarios effectively.
1. Review business capabilities required to achieve this business scenario.

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2. Review the best practices to understand how your business can improve in each area.
3. Review products and solutions to get quick time to value and build a roadmap as you increase your maturity.
To arrange a Business Capability Maturity Assessment, contact your Success Manager or Account Executive.

Explore Healthcare Payer Business Scenarios

Optimize Healthcare Payer Reach and Acquisition

Grow and maintain membership across existing business lines and innovation models.
Transform the Healthcare Payer Service Experience
Raise the bar for customer service by organizing member and patient interactions across your organization around individual needs.
Personalize Care in Healthcare Payer Organizations
Foster member and patient well-being with an approach to care that connects services and care management.

SEE ALSO:
Salesforce Business Scenarios: Quick Look

Optimize Healthcare Payer Reach and Acquisition

Grow and maintain membership across existing business lines and innovation models.
In today’s competitive and transforming market, it’s essential to attract and retain customers in order to grow. Healthcare payers lay the
foundations of success by making it easier for customers to shop, enroll, and find information about providers and benefits. Organizations
that arrange offerings to meet a variety of value and experience preferences appeal more to customers with different or changing needs.
To grow, organizations must meet customers in the right place at the right time with the right information, whether they’re individuals,
brokers, or employer groups. Support brokers and members by providing a comprehensive view of each individual, backed by engaging
analytics throughout the purchase journey. Optimize reach and attract new members, partners, and customers by streamlining discovery
and enrollment processes.

Success Metrics
Tracking key performance indicators (KPIs) helps you monitor the success of your changes.
Business KPIs
Business KPIs usually track revenue increases and cost reductions.
• Market share growth
• Increased member retention percentage
• Increased new member growth percentage
• Increased percentage of new business overall
• Increased members per product line or segment
• Increased revenue per product line or segment
• Increased number of RPFs won
• Increased conversion rates
• Reduced cost per acquisition
• Increased cross-selling

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Customer 360 Guide for Healthcare Payers Optimize Healthcare Payer Reach and Acquisition

• Increased percentage of growth from preferred partners

• Improved per member per month revenue (PMPM)
• Increased member, agent, and employer satisfaction ratings.
• Increased percentage of member capture in transition between business lines
Process KPIs
Data to support process KPI metrics can be pulled from Salesforce reports.
• Reduced days to acquire
• Decreased cycle time for quote-to-card process
• Decreased cost per acquisition
• Increased percentage of messages opened
• Increased conversion from messages
• Decreased average time to enroll
• Decreased number of cases per enrollment
• Increased number of self-service transactions
• Increased number of no touch transactions
• Decreased time for first call resolution

Products
These products can help you optimize your reach and acquisition capabilities.
• Health Cloud
• Marketing Cloud
• Experience Cloud for Healthcare
• for healthcare
• Shield
• Platform
• Salesforce Industries
• CRM Analytics for Healthcare
• Mulesoft (optional)
• CDP (optional)
• B2C Commerce (optional)
• Enablement Sites (myTrailhead) (optional)

Business Capabilities
To create positive customer experiences while increasing organizational efficiency, implement technical solutions and best practices
that can enhance your business capabilities.

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Customer 360 Guide for Healthcare Payers Optimize Healthcare Payer Reach and Acquisition

Target and Engage New and Existing Members

Grow your member base in the increasingly competitive payer space with relevant and timely outreach. Divide existing members
and prospective members into logical segments to better understand needs, inform customer experience strategy, and align support
strategies. Reach out to customers to provide information, education, and support based on actions taken online, benefits used, or
through a member support agent.
Help Members Research, Compare, and Select Health Insurance
Apply experience design principles and testing methods to create an intuitive shopping experience that helps members research
doctors, medications, benefits, and costs. Support conversion and retention by providing support at key moments, especially when
a new member is stalled in a purchasing journey.
Simplify and Automate Sales and Administration
Reduce operational costs and streamline enrollment by automating sales, quoting, and underwriting for sales agents and setup for
group sales administrators. Improve agent productivity and member satisfaction by providing each agent with proactive, contextual
information about each member customer. Increase revenue opportunities by partnering with and supporting brokers.
Solutions for Optimizing Reach and Acquisition
These solutions support capabilities within the Optimize Healthcare Payer and Reach business scenario in the Customer 360 Guide
for Healthcare Payers. For details about capabilities tied to these solutions, review each business scenario separately.

SEE ALSO:
Business Scenarios for Healthcare Payers
Salesforce Business Scenarios: Quick Look

Target and Engage New and Existing Members

Grow your member base in the increasingly competitive payer space with relevant and timely outreach. Divide existing members and
prospective members into logical segments to better understand needs, inform customer experience strategy, and align support
strategies. Reach out to customers to provide information, education, and support based on actions taken online, benefits used, or
through a member support agent.

Solutions
Beginning
• Marketing Cloud Contact Management
• Manage Campaigns with Health Cloud
Intermediate
• Getting Started: Marketing Cloud: Data and Segmentation Basics
• Getting Started with Marketing Cloud Email Studio
• Audience Segmentation
Advanced
• Set Up Marketing Cloud Connect
• Marketing Cloud Journeys and Automation
• Distributed Marketing
Best Practices
• Enhance Member Engagement

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• How to Enhance Your Open Enrollment Program

Capabilities

CAPABILITY BEST PRACTICES

Campaign Planning • Align on company business goals and key performance

Work across departments, including sales, administration, indicators.
member services, broker enablement, and care management, • To extend reach, create multi-channel campaigns.
to define and align on campaign and promotion strategy.
• Ensure a consistent experience by defining campaign planning
across all channels.
• Use member and prospect data when planning campaigns.

Channel Strategy and Mix • Align the channel strategy with the organization’s wider
Target customers with products, services, marketing, and go-to-market strategy.
channels, usually including direct sales, email, social media, • Collaborate with sales, marketing, business units, and other
marketing, call centers, B2B commerce, and partner relationship key leaders to define a clear channel strategy. Align with the
management. overall go-to-market strategy.
• Establish the role, objectives, and targets of each channel.
• Establish a framework for deciding the optimal customer,
product, and channel combinations for serving customers.
• Design for the downstream effects of the channel strategy on
your sales capability and the wider business.
• Create a consistent customer-centric experience across
channels.
• Create a uniform buying experience within and across channels.
• Use design thinking and customer-centric processes to build
experiences that align with how customers behave. Align with
their preferred way of being served wherever possible.

Lifecycle Marketing • Define the lifecycle of the customer by industry or organization.

Tailor marketing messages based on each stage of the A basic lifecycle consists of awareness, acquisition, onboarding,
customer’s lifecycle and touchpoints. engagement, and retention.
• Define customer needs and moments that matter to customers
at each stage of the lifecycle.
• Develop a well-defined customer lifecycle, and use it to
orchestrate messages across touchpoints.
• Use analytics to place contacts, leads, prospects, or customers
in a lifecycle stage.
• Develop a set of tactics for each stage of the lifecycle that
addresses customer needs and company goals. For example,
assign lapsed customers a win-back campaign when they
haven’t opened or clicked an email in the past 6 months.

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CAPABILITY BEST PRACTICES

• To orchestrate the correct messages and channels in each

lifecycle stage, build automations and audience segmentation
activities.
• To build automations and segment audiences, understand
what data you have and what data you need to gather to enrich
encounters and segmentation
• Implement a dynamic system that can move customers
through the current lifecycle stages and into new stages.
• Coordinate channels. Use personalization to engage customers
at each stage of the lifecycle.
• To create experiences that are lifecycle-driven, build customer
capability.

Marketing Vision and Value Proposition • Identify customer benefits, and link them to mechanisms for
Create a vision for how your brand delivers on the promise and how the product or service delivers value.
value to customers. Articulate the unique benefits of your • Map the basis for differentiation based on what drives target
brand, product, or service through marketing. market customers’ needs and desires. Identify brand strengths
and key areas of differentiation.
• Write the value proposition. Treat a value proposition like an
elevator pitch for the product or service.
• Ensure that the value proposition is based on what potential
customers value, not on what you think they value.

Partner Relationship Management (PRM) • Define goals and measurements for your partner program.
Identify, manage, and enable suitable partners to sell a defined • Understand the market opportunity based on research and
set of products and services to specific customers on behalf of trusted data.
the company.
• Set goals aligned to your company’s business objectives.
• Set goals for partners according to their maturity as a partner.
Be realistic about forecasted sales growth, especially for new
partners.
• Establish behavior-focused leading metrics, such as number
of deals registered, and results-focused lagging metrics, such
as attrition percent.
• Develop a reporting plan and dashboards analyzing the health
of your PRM program and partner engagement.
• Define interaction model with partners for lead management
and generation.
• Establish feedback loop to understand market needs,
• Enable partners to advocate for your products and answer
customer questions effectively.

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CAPABILITY BEST PRACTICES

Account Segmentation • Align segmentation to the organization’s business goals.

Identify and prioritize groups of customers with similar needs, • Classify accounts by segment.
growth potential, complexity, or other attributes. Align the
• Consider how segment attribute information is structured,
resources that match them.
captured, and maintained to support account segmentation.
• Consider how to handle complex segmentation scenarios in
a consistent way across the business.
• Consider which of the other business capabilities are influenced
by or supported through account segmentation.
• Consider the sales team structure, and match it to the account
segments and tiers.
• Consider how partners can add value across segments and
what insights can help them do so.
• Analyze the resources required to deliver the best servicing
approach.
• Consider the geography of the accounts.
• Allocate resources to the segments and tiers.

Account Segmentation Approach • Align segmentation to the organization’s wider business goals.
Define, prioritize, and combine segment attributes. Group • Ask sales, marketing, service, the business unit, and other key
accounts to support business goals. leaders to define the overarching business goals.
• Let sales leaders derive objectives that support business goals.
• Ask sales leaders and sales operations to identify key attributes
that help profile accounts. Use qualitative and quantitative
data such as industry, number of employees, and future
revenue potential.
• Combine multiple attributes for a well-rounded segmentation
approach.

Customer Segmentation for Marketing • Establish marketing goals for this segment.
Divide shoppers and prospects into logical segments to inform • Determine audience behavioral goals in context. For example,
customer experience strategy. what a consumer can reasonably be expected to do in a specific
circumstance. Good sources of behavioral data include:
– Conversions
– Specific site section visitors
– Top funnel visitors
– Users who were exposed to or clicked digital media
– High value visitors
– Visitor churn

• Formulate hypotheses about your audience that you want to

validate with segment creation and analysis.

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CAPABILITY BEST PRACTICES

• Before creating a segment, review existing segments to

determine if they’re a potential match.
• Create audience segments using multiple criteria including
behavior, preferences, demographics, and lifestyle. Prioritize
first-party data over second-party data, and second-party data
over third-party data.
• Name segments according to a standard pattern. Include
contextual words or abbreviations to make it easier to find and
share segments with others.
• Use recency and frequency information to modify your
segment definitions, if possible.
• Create an intuitive segment taxonomy. For example, a
classification schema that uses a hierarchy or folders.
• Examine the size of the audience. Consider whether it requires
immediate nurturing to grow.
• Determine if the segment is incremental to your existing or
target audience. If not, modify criteria for inclusion in the
segment.
• Document and share the why, how, overlap, details, and
persona of the segment you created.

Customer Segmentation for Service • Segment customers by demographics, behavior, geography,

Align corporate customer segmentation models to determine benefit, customer journey, or other relevant qualities.
service support and channel strategies. • Create customer profiles that provide useful information and
context for each customer.
• Tailor customer support experiences based on customer
segment. For example, target specific customer segments for
more or less personalized service based on spend or value.
• Address concerns before they arise, and make every customer
service interaction special.

Next Best Action • Use AI to predict, detect, profile, and classify cases across the
Provide proactive recommendations to service agents on what customer service organization.
to do next based on customer and industry data and built-in • Provide productivity gains by automatically relating
business logic. Use AI to predict, detect, profile, and classify multi-channel correspondence and resolution notes to the
cases across the customer service organization. case lifecycle.
• Use customer context and AI to recommend knowledge.
Recommend articles based on relevance to the request they’re
working on.

Recommend Knowledge • Enable suggested articles so that when a new case is saved,
Resolve cases more quickly by surfacing recommended the search engine automatically looks for articles that have
knowledge articles based on key service request characteristics. keywords in common with the admin-selected case fields.

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CAPABILITY BEST PRACTICES

Site Recommendations • Enable suggested articles so that when a new case is saved,
Place personalized product recommendations throughout the the search engine automatically looks for articles that have
customer experience to drive conversion and higher per-unit keywords in common with the admin-selected case fields.
transaction and average order value. • Define business goals for your recommendation strategy.
• Build out locations to deploy recommendations, such as
product details page, home page, category landing page, and
campaign pages.
• Conduct A/B testing to identify the optimal strategy for each
location.
• Deploy, monitor. and conduct A/B tests periodically to ensure
that strategies continue to perform.

Audience Activation • List all marketing campaigns and initiatives

Proactively target or suppress defined audiences in support of • Identify which audiences to target or suppress.
customer-centric marketing.
• To set realistic expectations, examine the match rates with the
marketing platforms and partners where the segment is
activated. If the estimated size of the matched segment
population is low, consider adding or activating more segments
that don’t have heavy overlap.
• Depending on your campaign objectives and category, monitor
audience reach and performance daily or weekly.
• Classify and document each campaign, initiative, and audience
using metadata descriptors.
• Keep documents updated to understand overlapping targeting
and audience targeting duplication.
• Measure the percentage of marketing campaigns and initiatives
that use targeting or suppression.
• Create target percentages by quarter. Include data showing
progress in monthly transformation roadmap reviews.
• Generate monthly reports for senior marketing and executive
leadership that highlight improvements in key progress
indicators.

Help Members Research, Compare, and Select Health Insurance

Apply experience design principles and testing methods to create an intuitive shopping experience that helps members research doctors,
medications, benefits, and costs. Support conversion and retention by providing support at key moments, especially when a new member
is stalled in a purchasing journey.

Solutions
Beginning
• Enable Health Cloud Provider Search

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Customer 360 Guide for Healthcare Payers Optimize Healthcare Payer Reach and Acquisition

• Health Cloud Provider Relationships and Search

Intermediate
• Individual Medicare Shop and Enroll Application
• Healthcare Enrollment in the Age of Digital and Unknowns
Advanced
• Discover Journey Builder
Business Process
• Customer Journey Worksheets

Capabilities

CAPABILITY BEST PRACTICES

Experience Design • Conduct user-focused design research.

The process of shaping brand interactions based on an • Define user goals in customer-centric language.
understanding of user behavior and expectations. Apply
– Use empathy to better understand users.
experience design principles to every marketing interaction,
message, and touchpoint. – Use human language, not system or tech-centric language.

• Consider the user’s context. For example, what location is the

customer in? Are they on the go, at their desk, using a kiosk,
or using a mobile device. Gather feedback in a non-intrusive
manner. Document and share findings from user-focused
design research with all business users, partners, and
stakeholders.
• Formulate, socialize, distribute, and conduct enablement on
experience design principles and guidelines specific to your
brand.
• Ensure that marketing campaigns, journeys, messages, and
interactions reflect experience design principles.
• Build in feedback loops that enable users, employees, and
partners to comment on experiences.
• Revisit user-focused design. Research and update experience
design principles and guidelines.

Test and Learn Approach • Identify third-party tools using your business goals and needs
Perform A/B and other tests to measure and improve your as a driver.
customer-centric site management efforts. • Implement, train, and give ownership to key resources within
the organization.
• Craft consistent messaging to the organization via executive
leadership that the organization includes testing and learning
as standard operating procedure.
• Align defined resources and tools to daily site operations,
business goals, and your roadmap.

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CAPABILITY BEST PRACTICES

• Create a testing plan that aligns with defined areas and

resources.
• Perform tests, and use the outcomes to inform other testing
practices.
• Provide test results to the organization.

Create New User Interfaces • Define a workflow process that defines and supports the
Work with experience designers to build front-end shopper creation of new user interfaces.
experiences. • To help everyone understand the scope of potential changes,
consider defining levels of effort. For example, use a t-shirt size
system where the level of effort is defined as small, medium,
large, or extra large.
• Benchmark and measure each improvement to determine and
identify return on investment.

Site Recommendations • Enable suggested articles so that when a new case is saved,
Place personalized product recommendations throughout the the search engine automatically looks for articles that have
customer experience to drive conversion and higher per-unit keywords in common with the admin-selected case fields.
transaction and average order value. • Define business goals for your recommendation strategy.
• Build out locations to deploy recommendations, such as
product details page, home page, category landing page, and
campaign pages.
• Conduct A/B testing to identify the optimal strategy for each
location.
• Deploy, monitor, and then conduct A/B tests periodically to
ensure that strategies continue to perform.

Preference Management • Make it easier for customers to state and change their content,
Enable customers to convey and manage their communication language, and channel preferences.
preferences, including for content, language, channels, and • Make it clear to customers how to manage basic privacy
basic privacy such as opt-outs. Use AI to infer preferences. considerations, such as opt-ins.
• Use AI to infer preferences.
• Streamline preference management across touchpoints by
incorporating preference management into your identity
system.

Case Notifications • Implement a system that allows for building, testing, and
Notify customers of key milestones as their service request releasing valuable system features with greater speed and
progresses. frequency while maintaining quality.
• Provide agents with a single source of truth for all case and
case collaboration data.
• Employ system administrations at scale, using employees’ or
customers’ preferred channels.

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CAPABILITY BEST PRACTICES

Case Collaboration • Create public chatter groups for each entitlement level that
Allow service agents to work cross-functionally and allows reps to ask their colleagues questions.
communicate in real time to address customer needs and • Create chatter groups for each service team.
resolve service requests.
• Create reports and dashboards for service leadership to monitor
chatter adoption.
• Encourage service leadership to use chatter.
• Use Quip for service, and connect Quip to Salesforce. Add Quip
as a tab on the case record so that agents can collaborate on
documents in real time.

Single View of the Customer • Identify the most critical data sources based on customer
Align relevant data sources at the individual customer level to lifecycle stages and moments that matter, prioritizing the top
support customer-centric marketing efforts. 3–5 customer journeys. Use the top journeys to inform business
requirements for data alignment or integration work.
• Create a data model with primary and secondary customer ID
fields and keys.
• Deploy an identity solution to connect users across devices
using deterministic and probabilistic approaches.
• Add secondary priority data sources.

Unified Agent Experience Approach • Integrate all support channels. Provide access using an
Improve customer satisfaction by smoothing agent-customer integrated interface that keeps information on context,
interactions, even when customers move from one agent to smooths interactions, and reduces repetition.
another. Deliver proactive, contextual information in a unified • Provide agents with relevant customer context so that they
way that empowers agents and reduces effort. can provide the best service. Equip agents with tools for
effective collaboration with other teams, such as case swarming
ability.
• Empower agents to gather and build on their collective
knowledge to improve the knowledge base and self-service
outcomes.
• Employ skills-based routing of cases to match customer
requests with agents who have the most suitable skills.
• Measure and improve the entire customer experience using
support data and customer analytics.

Self-Service Adoption • Formalize your business process, and carry it through to the
Monitor customers’ use of virtual self-service. Empower portal. For example, give agents access to the same FAQs as
customers to resolve self-service requests. Let service agents your customers.
and customers work across the business with digital • Identify your self-service users, and define the member
engagement across channels. experience.
• Create solutions that answer FAQs.
• Decide how to notify your users about the self-service portal.

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CAPABILITY BEST PRACTICES

Service Request Status • Define business rules about what notifications to send, when,
Ensure that your customers are notified of key milestones and by what channel. For example, at certain milestones or
throughout their service request, as defined by the business. status changes.
• Prioritize by customer preferences if that capability exists.
• Provide the ability to send emails or social notifications to
customers automatically or manually using macros or
configured workflow rules.
• Create email templates for case open, case close, and a case
that has been escalated.

Simplify and Automate Sales and Administration

Reduce operational costs and streamline enrollment by automating sales, quoting, and underwriting for sales agents and setup for group
sales administrators. Improve agent productivity and member satisfaction by providing each agent with proactive, contextual information
about each member customer. Increase revenue opportunities by partnering with and supporting brokers.

Solutions
Beginning
• Call Center Integration for Lightning Experience
• Creating a Call Center
• Display Information About a Patient or Member
• Automate Your Business Processes
Intermediate
• Customize Your Health Cloud Lightning Console
• Get a Complete View of Your Customers
Advanced
• Automating Sales and Improving Experiences (webinar)
• Channel Sales Guide

Capabilities

CAPABILITY BEST PRACTICES

Single View of the Customer • Identify the most critical data sources based on customer
Align relevant data sources at the individual customer level to lifecycle stages and moments that matter, prioritizing the top
support customer-centric marketing efforts. 3–5 customer journeys. Use the top journeys to inform business
requirements for data alignment or integration work.
• Create a data model with primary and secondary customer ID
fields and keys.

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Customer 360 Guide for Healthcare Payers Optimize Healthcare Payer Reach and Acquisition

CAPABILITY BEST PRACTICES

• Deploy an identity solution to connect users across devices

using deterministic and probabilistic approaches.
• Add secondary priority data sources.

Unified Agent Experience Approach • Integrate all support channels. Provide access using an
Improve customer satisfaction by smoothing agent-customer integrated interface that keeps information on context,
interactions, even when customers move from one agent to smooths interactions, and reduces repetition.
another. Deliver proactive, contextual information in a unified • Provide agents with relevant customer context so they can
way that empowers agents and reduces effort. provide the best service. Equip agents with tools for effective
collaboration with other teams, such as case swarming ability.
• Empower agents to gather and build on collective knowledge
to improve the knowledge base and self-service outcomes.
• Employ skills-based routing of cases to match customer
requests with agents who have the most suitable skills.
• Measure and improve the entire customer experience using
support data and customer analytics.

Self-Service Adoption • Formalize your business process, and carry it through to the
Monitor customers’ use of virtual self-service”. Empower portal. For example, give agents access to the same FAQs as
customers to resolve self-service requests. Let service agents your customers.
and customers work across the business with digital • Identify your self-service users, and define the member
engagement across channels. experience.
• Create solutions that answer commonly asked questions.
• Decide how to notify your users about the self-service portal.

Service Request Status • Define business rules about what notifications should be sent,
Ensure your customers are notified of key milestones, as defined when, and by what channel. For example, at certain milestones
by the business, to their service request. Should lead to or status changes.
reduction in follow-up by customers that have service requests • Prioritize by customer preferences if that capability exists.
open.
• Provide the ability to automatically or manually send emails
or social notifications to customers using macros or configured
workflow rules.
• Create email templates for case open, case close, and a case
that has been escalated.

Partner Relationship Management (PRM) • Define goals and measurements for your partner program.
Identify, manage, and enable suitable partners to sell a defined • Understand the market opportunity based on research and
set of products and services to specific customers on behalf of trusted data.
the company.
• Set goals that align with your company’s business objectives.
• Set goals for partners according to their maturity as a partner.
Be realistic about forecasted sales growth, especially for new
partners.

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Customer 360 Guide for Healthcare Payers Optimize Healthcare Payer Reach and Acquisition

CAPABILITY BEST PRACTICES

• Establish behavior-focused leading metrics, such as number

of deals registered, and results-focused lagging metrics, such
as attrition percent.
• Develop a reporting plan and dashboards analyzing the health
of your PRM program and partner engagement.

Account and Contact Management Approach • To ensure effective account and contact management, foster
Use this process to establish roles and responsibilities. Create, the right culture.
augment, govern, and manage accounts. • Align on the roles within the account and contact management
process, and assign specific resources to those roles.
• Align on expectations by role for the account and contact
management process.
• To encourage collaboration, create account teams.
• Establish a consistent account and contact management
approach.
• Define a process to create an account. Align on the criteria for
an account profile and what fields must be populated during
creation.
• To relate accounts to each other, create an account hierarchy.
• Set up a data governance team that owns and maintains
account ownership and rights to creation, editing, and deletion.
• Determine a modern data management (MDM) strategy for
accounts and whether to maintain accounts in Salesforce or
an outside database.
• To measure the success of account and contact management,
align on the leading and lagging indicators.
• Set up the reports and dashboards required to run the business
as it relates to account and contact management.

Account Segmentation Approach • Align segmentation to the organization’s wider business goals.
Define, prioritize, and combine segment attributes. Group • Ask sales, marketing, service, the business unit, and other key
accounts to support business goals. leaders to define the overarching business goals.
• Let sales leaders derive objectives that support business goals.
• Ask sales leaders and sales operations to identify key attributes
that help profile accounts. Use qualitative and quantitative
data, such as industry, number of employees, and future
revenue potential.
• Combine multiple attributes for a well-rounded segmentation
approach.

Account Tiering and Servicing 1. Prepare account segmentation programs for scale upfront.
Rank and prioritize accounts to define the appropriate pre- • Define rules for handling complexity, and understand how
and post-sales service levels for each tier. Define the the organization manages segmentation within multiple

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Customer 360 Guide for Healthcare Payers Optimize Healthcare Payer Reach and Acquisition

CAPABILITY BEST PRACTICES

segmentation with analysis, such as understanding how the tech stacks in each domain, including sales, service,
customer perceives a supplier. Look at channel relationships operations, and channel strategy and mix.
like box shifter, solution provider, and strategic provider. • Gather existing account data, and assess the completeness
and quality of the selected segmentation attributes.

2. Assess the consistency and availability of key segmentation

attributes. For example, industry classification codes can differ
from region to region.
3. To empower cross-functional teams, align on an approach for
analyzing tiers, allocating accounts, and establishing service
for each tier.
4. To build the most complete and consistent dataset, add
missing data.
5. Ensure that all relevant elements of the tech stack are updated
to surface the tiers.
6. Define processes that support classification of new accounts,
and define processes to update an account’s assigned tier over
time. Assign clear ownership of both processes.
7. Deploy tiering.

Sales Enablement • Align on the tools and processes for creating, contacting, and
Provide sellers with the product knowledge and selling managing your accounts, contacts, and leads.
practices to facilitate sales. • Use enablement and training to emphasize the behaviors that
are necessary to manage and gain insights from the pipeline.
• Educate sellers on their compensation plans and performance
objectives that connect to the business goals.
• Determine what tools salespeople require to do their job based
on role or otherwise.
• Create a plan for creating, maintaining, and sharing materials
that the sales team uses.
• Use sales tools to provide sellers with updated customer,
product, and industry knowledge. And use sales tools to
streamline interactions between customer and seller and
interactions between sales managers and sellers.

Sales Methodology Approach • Ensure that a strong correlation exists between a sales
Select and enable sales with the sales methodology that guides methodology and sales performance. Align on a channel
sellers on actions that reflect the desired business outcomes. methodology. Set realistic expectations, create clear success
Keep sales methodology updated based on trends, such as metrics, and seek cross-functional executive sponsorship.
forecasting approach and coaching by sales management. • Implement paths that show each stage of the sales process.
Provide Guidance for Success at each stage to help users align
with the forecasting process.
• Update, revise, and review sales methodology continually.

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Customer 360 Guide for Healthcare Payers Optimize Healthcare Payer Reach and Acquisition

CAPABILITY BEST PRACTICES

• Forecast accurate data that provides tips, links, and best

practices for sales methodology.
• Align the default forecast categories with opportunity stages,
and ensure that there’s a clear understanding of when and
how a forecast category can be changed. Reward accurate
forecasts in sales methodology. Analyze inaccurate forecasts
and target sales teams for development or coaching.

Virtually Lead Through Change • Determine how the virtual environment impacts these existing
Motivate sellers, strengthen essential business partnerships, capabilities.
and provide direction and inspiration to customers and – Account segmentation
employees when virtual selling disrupts the field sales channel.
– Channel strategy
– Sales analytics
– Territory management
– Pipeline strategy and programs
– Sales support
– Sales performance management
– Sales enablement

• Establish a process that ensures open and transparent

communication channels throughout all levels of the
organization.
• Enhance communications with videos and recordings.
• Stay aligned and keep connected by establishing a meeting
framework.
• Drive alignment through extended stakeholder participation
across verticals.
• Create a process that motivates reps and helps them learn new
ways of working that embrace digital options.
• Adjust existing goals, processes, and technology to achieve
digital transformations.
• Communicate and align changes with the company’s vision,
values, and objectives.
• Elevate virtual selling to become a primary lens that develops
the go-to-market strategy.
• Measure and review channel performance in the assisted digital
engagements.
• Regularly forecast, measure, and analyze sales, cost-to-serve,
and satisfaction metrics by channel. Include service and sales
channel engagements. Use the results to identify areas of under
performance and over performance.

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Customer 360 Guide for Healthcare Payers Optimize Healthcare Payer Reach and Acquisition

CAPABILITY BEST PRACTICES

• Ensure sales leaders and sales teams have a complete view of

the customer in a single, unified system, including interactions
on all sales channels.

Solutions for Optimizing Reach and Acquisition

These solutions support capabilities within the Optimize Healthcare Payer and Reach business scenario in the Customer 360 Guide for
Healthcare Payers. For details about capabilities tied to these solutions, review each business scenario separately.

Target and Engage New and Existing Members

Learn more on page 8 and review capabilities for this area.
Beginning
• Marketing Cloud Contact Management
• Manage Campaigns with Health Cloud
Intermediate
• Getting Started: Marketing Cloud: Data and Segmentation Basics
• Getting Started with Marketing Cloud Email Studio
• Audience Segmentation
Advanced
• Set Up Marketing Cloud Connect
• Marketing Cloud Journeys and Automation
• Distributed Marketing
Best Practices
• Enhance Member Engagement
• How to Enhance Your Open Enrollment Program

Help Members Research, Compare, and Select Health Insurance

Learn more on page 13 and review capabilities for this area.
Beginning
• Enable Health Cloud Provider Search
• Health Cloud Provider Relationships and Search
Intermediate
• Individual Medicare Shop and Enroll Application
• Healthcare Enrollment in the Age of Digital and Unknowns
Advanced
• Discover Journey Builder

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Customer 360 Guide for Healthcare Payers Transform the Healthcare Payer Service Experience

Business Process
• Customer Journey Worksheets

Simplify and Automate Sales and Administration

Learn more on page 17 and review capabilities for this area.
Beginning
• Call Center Integration for Lightning Experience
• Creating a Call Center
• Display Information About a Patient or Member
• Automate Your Business Processes
Intermediate
• Customize Your Health Cloud Lightning Console
• Get a Complete View of Your Customers
Advanced
• Automating Sales and Improving Experiences (webinar)
• Channel Sales Guide

Transform the Healthcare Payer Service Experience

Raise the bar for customer service by organizing member and patient interactions across your organization around individual needs.
Many call centers are organized according to the healthcare organization’s internal structure, leaving customers to navigate a maze of
different contact points, each with different knowledge about the customer’s needs and history. It’s critical that insurers make it easier
for individuals to interact with the organization.
Transform service by:
• Creating a connected and frictionless experience tailored to the member across all touchpoints.
• Building a holistic member view that integrates data across pre-sales engagements, administrative services, clinical and care
management, and marketing communications.
• Equipping agents with all the information about each member so that they can anticipate customer needs, provide exceptional
service, and increase the likelihood of creating customers for life.

Success Metrics
Tracking key performance indicators (KPIs) helps you monitor the success of your changes.
Business KPIs
Business KPIs usually track revenue increases and cost reductions.
• Increased member and physician satisfaction ratings
• Reduced cost per call
• Increased average number of calls per agent
• Decreased agent time between calls
• Faster agent onboarding
• Reduced agent turnover

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Customer 360 Guide for Healthcare Payers Transform the Healthcare Payer Service Experience

• Increased call quality consistency

Process KPIs
Data to support process KPI metrics can be pulled from Salesforce reports.
• Increased number of self-service transactions
• Increased average number of calls per agent
• Decreased call handle time
• Increased first call resolution percentage
• Increased call deflection to chat bots

Products
These products can help you transform your service experience.
• Health Cloud
• Marketing Cloud
• Platform
• Tableau
• CRM Analytics
• Shield
• Mulesoft (optional)
• Data Cloud (optional)
• Interaction Studio (optional)
• Slack (optional)

Business Capabilities
To deliver solutions, implement technical solutions and best practices in your business capabilities that support service transformation

Enable Agents with a Holistic Member View

Improve customer satisfaction and support the agent experience by managing data to protect customer preferences and provide
agents with a complete view of customer interactions.
Handle Inquiries Consistently and Efficiently in Health Cloud
Ensure that members’ needs are resolved in a timely manner by giving every agent all relevant information, useful recommendations,
and the ability to collaborate. Keep members informed about the status of their inquiry.
Manage Sales, Administration, and Enrollment Inquiries
Deliver smooth interactions when servicing requests for documents, letters, statements, and other documents.
Resolve Member Plan and Care Related Inquiries and Follow-Ups
Provide agents with complete member information and case information. Allow for swarming on inquiries, and ensure that an
updated knowledge base is available to agents.
Handle Member Plan Transactions
Support member engagement and retention by making sure that agents have the right skills to complete key member transactions.

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Customer 360 Guide for Healthcare Payers Transform the Healthcare Payer Service Experience

Provide Proactive and Prescriptive Member Service

Empower agents and generate revenue from your call center by providing agents with a complete view of each customer.
Understanding each member’s history and needs helps agents provide excellent service and determine the next best action.
Engage Members During the Quote to Card Journey
Establish lifelong relationships by engaging prospective and current customers with relevant content and offers right from the
beginning of their journey.
Self-Service for Members
Meet members’ expectations for quick and reliable responses to inquiries by providing self-service options. Provide relevant, usable
interfaces that support members in completing their own inquiries and transactions.
Manage Contact Center Operations
Do more than set up agents to receive calls. Empower them with knowledge updates and new skills. Also, focus the call center on
data governance and key compliance factors. Optimize training and management.
Enable Agents to Handle Provider Inquiries in Health Cloud
Improve interactions with providers to help them better handle care requests and manage member health. Give providers tools to
manage their network and understand member benefits. Provide current provider information in member searches.
Solutions for Transforming the Healthcare Payer Experience
These solutions support capabilities within the Transform the Healthcare Payer Experience business scenario in the Customer 360
Guide for Healthcare Payers. For details about capabilities tied to these solutions, review each business scenario separately.

SEE ALSO:
Business Scenarios for Healthcare Payers
Salesforce Business Scenarios: Quick Look

Enable Agents with a Holistic Member View

Improve customer satisfaction and support the agent experience by managing data to protect customer preferences and provide agents
with a complete view of customer interactions.

Solutions
Beginning
• Get to Know the Health Cloud Console
• Display a Patient’s Life Events
• Set Up Social Determinants to Assist High-Risk Patients and Members
• Customize the Timeline View
• Customize Patient Card Data
• Customize Patient Data Displays
• Learn to Customization Page Layouts
• Take a Look at the Household Data Model
Intermediate
• Use Mulesoft to Integrate with Health Cloud
• Interoperability and the Clinical Data Model

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Customer 360 Guide for Healthcare Payers Transform the Healthcare Payer Service Experience

Advanced
• Salesforce Integration: Guide to Healthcare Interoperability (white paper)
• MuleSoft Accelerator for Healthcare

Capabilities

CAPABILITY BEST PRACTICES

Unified Agent Experience Approach • Integrate all support channels. Provide access using an
Improve customer satisfaction by smoothing agent-customer integrated interface that keeps information in context, smooths
interactions, even when customers move from one agent to interactions, and reduces repetition.
another. Deliver proactive, contextual information in a unified • Provide agents with relevant customer context so they can
way that empowers agents and reduces effort. provide the best service. Equip agents with tools for effective
collaboration with other teams, such as case swarming ability.
• Empower agents to gather and build on collective knowledge
to improve the knowledge base and self-service outcomes.
• Employ skills-based routing of cases to match customer
requests with agents who have the most suitable skills.
• Measure and improve the entire customer experience using
support data and customer analytics.

Data Governance • To ensure quality, availability, and compliance, strengthen data

Deliver positive customer experiences by managing data assets governance.
and usage in accordance with organizational policy and • Support testing, marketing measurement, and sentiment
relevant regulations, including data stewardship, quality, analysis by implementing a single view of the customer.
integrity, privacy, and security.
• Give business users access to data and insights so that they
can base decisions on facts.
• Make decisions using customer-centric key performance
indicators, such as customer satisfaction, net promoter score,
and customer lifetime value.
• Grant all internal stakeholders insight into product usage and
performance. Provide customer stakeholders with proactive
insights.
• Develop a comprehensive, policy-oriented governance
framework that ensures on-time delivery of business
capabilities at the metadata level and APIs across all systems
and processes.
• To capture all business process and data flows, connect
corporate, market, and business teams’ data with back-office
infrastructure and call centers.
• Create an omni-channel journey for segments, contact groups,
values, and region with product strategy and mix.
• Integrate IT and business operations so that they function as
one team focused on customer success.

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CAPABILITY BEST PRACTICES

• Organize teams around desired outcomes, not functional roles

or silos in systems.
• Follow a documented process to gather, interpret, and share
all insights and product- and service-related data.

Single View of the Customer • Identify the most critical data sources based on customer
Align relevant data sources at the individual customer level to lifecycle stages and moments that matter, prioritizing the top
support customer-centric marketing efforts. 3–5 customer journeys. Use the top journeys to inform business
requirements for data alignment or integration work.
• Create a data model with primary and secondary customer ID
fields and keys.
• Deploy an identity solution to connect users across devices
using deterministic and probabilistic approaches.
• Add secondary priority data sources.

Consent Management • Make it easy for customers to manage right-to-be-forgotten

Honor customer preferences for use of data and data tasks.
portability. Comply with consent rights policies and regulations. • Ensure that customer data policies are compliant with current
regulations and that they can be easily adapted to changes in
regulations or by geographic area. Policies include:
– Ensure that data processes port customers’ data to other
systems as much as possible.
– Minimize degradation of the value of and ability to use
customer data in other systems.
– Give customers flexibility to manage their opt-in or opt-out
status.

Handle Inquiries Consistently and Efficiently in Health Cloud

Ensure that members’ needs are resolved in a timely manner by giving every agent all relevant information, useful recommendations,
and the ability to collaborate. Keep members informed about the status of their inquiry.

Solutions
Beginning
• Increase Your Productivity in the Service Console
• Flow Builder for Service
• Service Cloud Routing
• Get to Know Health Cloud Console
Intermediate
• Flows
• Flow Builder for Service

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Customer 360 Guide for Healthcare Payers Transform the Healthcare Payer Service Experience

• Salesforce Knowledge
• Salesforce Knowledge Help and Resources
• Entitlements
Advanced
• Digitize Document Management with Intelligent Document Automation
• Service Agent Scripts for Salesforce Flow
• Transcribe Calls with API
• Create Transcripts During a Call
• Working with Call Transcripts
• Let Customers Request that Support Get Back to Them
Resources
• Shield Learning Map

Capabilities

CAPABILITY BEST PRACTICES

Single View of the Customer • Identify the most critical data sources based on customer
Align relevant data sources at the individual customer level to lifecycle stages and moments that matter, prioritizing the top
support customer-centric marketing efforts. 3–5 customer journeys. Use the top journeys to inform business
requirements for data alignment or integration work.
• Create a data model with primary and secondary customer ID
fields and keys.
• Deploy an identity solution to connect users across devices
using deterministic and probabilistic approaches.
• Add secondary priority data sources.

Unified Agent Experience Approach • Integrate all support channels. Provide access using an
Improve customer satisfaction by smoothing agent-customer integrated interface that keeps information in context, smooths
interactions, even when customers move from one agent to interactions, and reduces repetition.
another. Deliver proactive, contextual information in a unified • Provide agents with relevant customer context so they can
way that empowers agents and reduces effort. provide the best service. Equip agents with tools for effective
collaboration with other teams, such as case swarming ability.
• Empower agents to gather and build on collective knowledge
to improve the knowledge base and self-service outcomes.
• Employ skills-based routing of cases to match customer
requests with agents who have the most suitable skills.
• Measure and improve the entire customer experience using
support data and customer analytics.

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CAPABILITY BEST PRACTICES

Knowledge Management Approach • Align on the article lifecycle stages and actions associated with
Capturing and distributing reusable, relevant, and accurate each stage. Common stages are draft, review, approve, publish,
knowledge content to customers and partners across one or and archive.
more internal or external channels. • Identify owners for each stage of the lifecycle and approval
process by article type or data category.
• Identify subject matter experts who can write articles about
your products and services.
• Enable Email-to-Case so that agents can send articles to
customers.
• To help track individual, group, and organizational article
quality trends and effectiveness across time, install the Article
Quality Index managed package from AppExchange.
• Install the Knowledge Article Feedback managed package from
AppExchange.
• To help find and classify articles, questions, or ideas, define
data categories.
• Enable feed tracking on knowledge articles and tagging on
knowledge articles.
• Add an actions and recommendations Lightning Web
Component to the case page layout or console layout.
• Ensure that case titles are accurate, clear, and follow the
structure defined by the business or IT.
• Decide which languages you want to translate in-house versus
sending articles to a localization vendor. If there are at least
three languages, ensure that there’s a version management
process in place for all translated articles.
• Ensure that communications go out to team members involved
in the knowledge lifecycle process.
• To help find and classify articles, questions, or ideas, define
data categories.
• Define article record types.
• Enable feed tracking on knowledge articles.
• Enable tagging on knowledge articles.
• Ensure that articles are rated so that agents can get an
understanding of how effective the article is.

Recommend Knowledge • Enable suggested articles so that when a new case is saved,
Resolve cases more quickly by surfacing recommended the search engine automatically looks for articles that have
knowledge articles based on key service request characteristics. keywords in common with the admin-selected case fields.

Case Notifications • Implement a system that allows for building, testing, and
Notify customers of key milestones as their service request releasing valuable system features with greater speed and
progresses. frequency while maintaining quality.

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Customer 360 Guide for Healthcare Payers Transform the Healthcare Payer Service Experience

CAPABILITY BEST PRACTICES

• Provide agents with a single source of truth for all case and
case collaboration data.
• Employ system administrations at scale, using employees’ or
customers’ preferred channels.

Case Collaboration • Create public chatter groups for each entitlement level that
Allow service agents to work cross-functionally and allows reps to ask their colleagues questions.
communicate in real time to address customer needs and • Create chatter groups for each service team.
resolve service requests.
• Create reports and dashboards for service leadership to monitor
chatter adoption.
• Encourage service leadership to use chatter.
• Use Quip for service, and connect Quip to Salesforce. Add Quip
as a tab on the case record so that agents can collaborate on
documents in real time.

Manage Sales, Administration, and Enrollment Inquiries

Deliver smooth interactions when servicing requests for documents, letters, statements, and other documents.

Solutions
Beginning
• Increase Productivity in Console
• Flow Builder for Service
• Set Up and Use Quick Text
Intermediate
• Design Your Quick Text Strategy
• Salesforce Knowledge
• Set Up Salesforce Knowledge
• Lightning Knowledge Setup and Customization
Advanced
• Digitize Document Management with Intelligent Document Automation

Capabilities

CAPABILITY BEST PRACTICES

Single View of the Customer • Identify the most critical data sources based on customer
Align relevant data sources at the individual customer level to lifecycle stages and moments that matter, prioritizing the top
support customer-centric marketing efforts. 3–5 customer journeys. Use the top journeys to inform business
requirements for data alignment or integration work.

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Customer 360 Guide for Healthcare Payers Transform the Healthcare Payer Service Experience

CAPABILITY BEST PRACTICES

• Create a data model with primary and secondary customer ID

fields and keys.
• Deploy an identity solution to connect users across devices
using deterministic and probabilistic approaches.
• Add secondary priority data sources.

Unified Agent Experience Approach • Integrate all support channels. Provide access using an
Improve customer satisfaction by smoothing agent-customer integrated interface that keeps information in context, smooths
interactions, even when customers move from one agent to interactions, and reduces repetition.
another. Deliver proactive, contextual information in a unified • Provide agents with relevant customer context so they can
way that empowers agents and reduces effort. provide the best service. Equip agents with tools for effective
collaboration with other teams, such as case swarming ability.
• Empower agents to gather and build on collective knowledge
to improve the knowledge base and self-service outcomes.
• Employ skills-based routing of cases to match customer
requests with agents who have the most suitable skills.
• Measure and improve the entire customer experience using
support data and customer analytics.

Resolve Member Plan and Care Related Inquiries and Follow-Ups

Provide agents with complete member information and case information. Allow for swarming on inquiries, and ensure that an updated
knowledge base is available to agents.

Solutions
Beginning
• Care Request Lightning Page
• Handle Care Requests
• Configure and Customize Care Request
• Enable Users to Verify Patient Benefits
• Health Cloud Provider Relationships and Search
• Enable Provider Search
Intermediate
• Set Up Utilization Management
• Install the Claims Data Model
• Connect to Claims Data
• Set Up Provider Relationship Cards
• Configure Provider Search
Advanced
• Medication Management

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Customer 360 Guide for Healthcare Payers Transform the Healthcare Payer Service Experience

Capabilities

CAPABILITY BEST PRACTICES

Unified Agent Experience Approach • Integrate all support channels. Provide access using an
Improve customer satisfaction by smoothing agent-customer integrated interface that keeps information in context, smooths
interactions, even when customers move from one agent to interactions, and reduces repetition.
another. Deliver proactive, contextual information in a unified • Provide agents with relevant customer context so that they
way that empowers agents and reduces effort. can provide the best service. Equip agents with tools for
effective collaboration with other teams, such as case swarming
ability.
• Empower agents to gather and build on collective knowledge
to improve the knowledge base and self-service outcomes.
• Employ skills-based routing of cases to match customer
requests with agents who have the most suitable skills.
• Measure and improve the entire customer experience using
support data and customer analytics.

Case Notifications • Implement a system that allows for building, testing, and
Notify customers of key milestones as their service request releasing valuable system features with greater speed and
progresses. frequency while maintaining quality.
• Provide agents with a single source of truth for all case and
case collaboration data.
• Employ system administrations at scale, using employees’ or
customers’ preferred channels.

Handle Member Plan Transactions

Support member engagement and retention by making sure that agents have the right skills to complete key member transactions.

Solutions
Beginning
• Take a Look at the Household Data Model
• Manage Your Patients and Members Households
• Health Cloud Provider Relationships and Search
• Enable Provider Search for Users
Intermediate
• Connect to Claims Data
Advanced
• Support Intelligent Document Automation
• Use Intelligent Document Automation
• Mulesoft Accelerators for Healthcare

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Customer 360 Guide for Healthcare Payers Transform the Healthcare Payer Service Experience

Capabilities

CAPABILITY BEST PRACTICES

Skills Management • Align to a skills matrix for each service agent group.
Train agents as new products and services are introduced. • Outline which skills are needed for each tier, product, and
service.
• Require training and certifications for each service tier.
• Allow Omni-Channel to route cases to agents or queues with
the right skills within a defined queue.

Provide Proactive and Prescriptive Member Service

Empower agents and generate revenue from your call center by providing agents with a complete view of each customer. Understanding
each member’s history and needs helps agents provide excellent service and determine the next best action.

Solutions
Beginning
• Einstein Next Best Action (documentation)
• Einstein Next Best Action (Trailhead module)
• Enable Care Team Gaps
Intermediate
• Recommendation Automation with Einstein Next Best Action
• Put Predictions into Action with Next Best Action
Advanced
• Manage Patient Risk with Analytics for Health Cloud: Risk Stratification

Capabilities

CAPABILITY BEST PRACTICES

Single View of the Customer • Identify the most critical data sources based on customer
Align relevant data sources at the individual customer level to lifecycle stages and moments that matter, prioritizing the top
support customer-centric marketing efforts. 3–5 customer journeys. Use the top journeys to inform business
requirements for data alignment or integration work.
• Create a data model with primary and secondary customer ID
fields and keys.
• Deploy an identity solution to connect users across devices
using deterministic and probabilistic approaches.
• Add secondary priority data sources.

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Customer 360 Guide for Healthcare Payers Transform the Healthcare Payer Service Experience

CAPABILITY BEST PRACTICES

Unified Agent Experience Approach • Integrate all support channels. Provide access using an
Improve customer satisfaction by smoothing agent-customer integrated interface that keeps information in context, smooths
interactions, even when customers move from one agent to interactions, and reduces repetition.
another. Deliver proactive, contextual information in a unified • Provide agents with relevant customer context so that they
way that empowers agents and reduces effort. can provide the best service. Equip agents with tools for
effective collaboration with other teams, such as case swarming
ability.
• Empower agents to gather and build on collective knowledge
to improve the knowledge base and self-service outcomes.
• Employ skills-based routing of cases to match customer
requests with agents who have the most suitable skills.
• Measure and improve the entire customer experience using
support data and customer analytics.

Next Best Action • Use AI to predict, detect, profile, and classify cases across the
Provide proactive recommendations to service agents on what customer service organization.
to do next based on customer and industry data and built-in • Relate multi-channel correspondence and resolution notes to
business logic. the case lifecycle automatically to increase productivity.
• Use customer context and AI to recommend knowledge.
Recommend articles based on relevance to the request they’re
working on.

Cross-Sell and Upsell • Identify the right trigger point for cross-sell and upsell for your
Prioritize, develop, manage, and measure customer cross-sell organization. Think beyond the standard scenario of
and upsell offers and journeys. recommending one product based on another.
• Use your insights to build cross-sell and upsell campaigns.
• Use lifecycle and behavioral data to enter customers into
personalized cross-sell and upsell journeys on the appropriate
channels.
• Use personalization to deliver the right message to customers.
• Use AI to recommend correct cross-sell or upsell opportunities.
• Identify the correct data points to use to activate cross-sell and
upsell campaigns. For example, the expiration date of an
insurance policy or a medication refill. Deliver messages
through the correct channels based on past behavior.
• Apply the correct tactic to drive the highest conversion rates
possible. Consider user-generated content, expert
recommendations, and discounts and promotions.
• Use real-time interaction management to coordinate cross-sell
and upsell messages with other eligible messages.

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Engage Members During the Quote to Card Journey

Establish lifelong relationships by engaging prospective and current customers with relevant content and offers right from the beginning
of their journey.

Solutions
Beginning
• Email Marketing Best Practices
• Email Design Toolkit
• Manage Campaigns with Health Cloud
Intermediate
• Getting Started: Marketing Cloud: Data and Segmentation Basics
• Getting Started with Marketing Cloud Email Studio
• Manage Customer Journeys
• Audience Segmentation
Advanced
• Advanced Customer Journeys

Capabilities

CAPABILITY BEST PRACTICES

Person and Journey Mapping • Create a questionnaire that maps customer assets and liabilities
Document interactions a customer has with a brand around a into different segments.
single objective, product, or service. Organizations use • Feed net worth into a segmentation model.
persona-driven journey mappings to better understand the
• Maintain customer lifetime value (CLV) analytics across business
unique needs and interactions of different types of customers.
lines to understand the customer’s commercial potential.
• Consider which sales and service channels are profitable for
the customer segment and margins.
• Refresh data based on automated customer analytics such as
tax filing and deposit information.
• Assign customers to bankers based on their segment and
needs.

Campaign Strategy • Regularly review data and analytics to better understand your
Base promotional strategies on business goals and key customer behaviors.
performance indicators. • Benchmark promotions, and then use analytics to measure
success.
• Understand your organizational business goals.
• Use the data to inform your promotional strategy, including
types of promotions, products used, frequency, and cadence.

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Customer 360 Guide for Healthcare Payers Transform the Healthcare Payer Service Experience

CAPABILITY BEST PRACTICES

Site Recommendations • Enable suggested articles so that when a new case is saved,
Place personalized product recommendations throughout the the search engine automatically looks for articles that have
customer experience to drive conversion and higher per-unit keywords in common with the admin-selected case fields.
transaction and average order value. • Define business goals for your recommendation strategy.
• Build out locations to deploy recommendations, such as
product details page, home page, category landing page, and
campaign pages.
• Conduct A/B testing to identify the optimal strategy for each
location.
• Deploy, monitor, and then conduct A/B tests periodically to
ensure that strategies continue to perform.

Self-Service for Members

Meet members’ expectations for quick and reliable responses to inquiries by providing self-service options. Provide relevant, usable
interfaces that support members in completing their own inquiries and transactions.

Solutions
Beginning
• The Importance of Self-Service Portals
• Experience Cloud Sites for Healthcare
• Set Up an Experience Cloud Site
• Understand the Basics of Experience Cloud
• Configure Your Self-Registration Page
• Learn About Einstein Bots Compliance
• What is a Chatbot
• Chat with Your Customers on Your Website
Intermediate
• Secure Your Experience Cloud Site
• Enable Cases for Experience Cloud Site
• Add a Flow to an Experience Builder Site
• Customize Your Chat Implementation
• Setup Chat with a Guided Flow
Advanced
• Improve Experience Cloud Site Performance
• Configure Search Functionality in Experience Cloud
• Manage Your Community Email Notifications
• Data Model for Peer to Peer Conversations in Experience Cloud
• Einstein Bots

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Customer 360 Guide for Healthcare Payers Transform the Healthcare Payer Service Experience

Capabilities

Capability Best Practices

Self-Service Adoption • Formalize your business process, and carry it through to the
Monitor customers’ use of virtual self-service. Empower portal. For example, give agents access to the same FAQs as
customers to resolve self-service requests. Enable service agents your customers.
and customers to work across the business with digital • Identify your self-service users, and define the member
engagement across channels. experience.
• Create solutions that answer commonly asked questions.
• Decide how to notify your users about the self-service portal.

Service Request Status • Define business rules about what notifications to send, when,
Ensure that your customers are notified of key milestones in and by what channel. For example, at certain milestones or
their service request, as defined by the business. status changes.
• Prioritize by customer preferences if that capability exists.
• Provide the ability to automatically or manually send emails
or social notifications to customers using macros or configured
workflow rules.
• Create email templates for case open, case close, and a case
that has been escalated.

Experience Design • Conduct user-focused design research.

The process of shaping brand interactions based on an • Define user goals in customer-centric language.
understanding of user behavior and expectations. Apply
– Use empathy to better understand users.
experience design principles to every marketing interaction,
message, and touchpoint. – Use human language, not system or tech-centric language.

• Consider the user’s context. For example, what location is the

customer in? Are they on the go, at their desk, using a kiosk,
or using a mobile device?
• Gather feedback in a non-intrusive manner.
• Document and share findings from user-focused design
research with all business users, partners, and stakeholders.
• Formulate, socialize, distribute, and conduct enablement on
experience design principles and guidelines specific to your
brand.
• Ensure that marketing campaigns, journeys, messages, and
interactions reflect experience design principles.
• Build in feedback loops that enable users, employees, and
partners to comment on experiences.
• Revisit user-focused design. Research and update experience
design principles and guidelines.

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Customer 360 Guide for Healthcare Payers Transform the Healthcare Payer Service Experience

Manage Contact Center Operations

Do more than set up agents to receive calls. Empower them with knowledge updates and new skills. Also, focus the call center on data
governance and key compliance factors. Optimize training and management.

Solutions
Beginning
• Analyze Your Service Data in Salesforce
• Get Insights from Your Health Cloud Data with CRM Analytics
• Set Up a Customer Feedback Survey
Intermediate
• Set Up CRM Analytics for Healthcare
• Set Up Omni Supervisor
Advanced
• Workforce Engagement
• Focus on Training
Resources
• Service & Supports Dashboards Package
• Preconfigured Service Cloud Dashboards
• Omni Channel Performance Dashboard

Capabilities

CAPABILITY BEST PRACTICES

Scheduling and Workforce Optimization Approach • To understand their current process and deliverables to service
Balance customer satisfaction, service levels, workforce operations, engage with the workforce management (WFM)
scheduling, operational costs, and other key performance team.
metrics to maximize employees’ time. • Review the current scheduling process and outputs such as
agent schedule.
• Understand calculations that determine how many agents are
needed, based on:
– Service level and speed of answer (80/20 or 80/30)
– Productivity and how it’s calculated (occupancy and
utilization)
– The cost to service compromise
– Erlang calculations used for staffing needs
– The relationship between contact center, skill group size,
and efficiency

• Determine usage of the Erlang Calculator tool for scheduling.

What is the number of calls expected over a time period, for
example, per half hour? What’s the average Handling Time

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Customer 360 Guide for Healthcare Payers Transform the Healthcare Payer Service Experience

CAPABILITY BEST PRACTICES

(AHT)? What is the service level, target answer time, maximum
occupancy, and shrinkage? The calculator uses these details
to calculate the number of advisors required to handle the
expected call volumes over the reporting period. The calculator
gives exact figures for service level and occupancy to account
for decimal point numbers.
• Review real-time reports generated for adherence and
variations.
• Understand operations team processes for managing real-time
spikes, service level adherence, and performance management.
• Assess data about following causes of unexpected spikes in
contact volumes at the organizations.
• Assess how to manage attendance and adherence to
schedules.
• Understand reaction strategy, including any service disruption
strategy in place.
• Schedule a business continuity plan (BCP) review. The likelihood
of these disasters varies according to location. Ensure that the
BCP is an all-encompassing document that identifies any type
of disaster, the impact of that disaster, and the recovery
procedures.

Knowledge Management Approach • Align on the article lifecycle stages and actions associated with
Capture and distribute reusable, relevant, and accurate each stage. Common stages are draft, review, approve, publish,
knowledge content across one or more channels internally and archive.
and externally to customers and partners. • Identify owners for each stage of the lifecycle and approval
process by article type or data category.
• Identify subject matter experts who can write articles about
your products and services.
• Enable Email-to-Case so that agents can send articles to
customers.
• To help track individual, group, and organizational article
quality trends and effectiveness across time, install the Article
Quality Index managed package from AppExchange.
• Install the Knowledge Article Feedback managed package from
AppExchange.
• To help find and classify articles, questions, or ideas, define
data categories.
• Enable feed tracking on knowledge articles and tagging on
knowledge articles.
• Add an actions and recommendations Lightning Web
Component to the case page layout or console layout.

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CAPABILITY BEST PRACTICES

• Ensure that case titles are accurate, clear, and follow the
structure defined by the business or IT.
• Decide which languages you want to translate in-house versus
sending articles to a localization vendor. If there are at least
three languages, ensure that there’s a version management
process in place for all translated articles.
• Ensure that communications go out to team members involved
in the knowledge lifecycle process.
• To help find and classify articles, questions, or ideas, define
data categories.
• Define article record types.
• Enable feed tracking on knowledge articles.
• Enable tagging on knowledge articles.
• Ensure that articles are rated so that agents can get an
understanding of how effective the article is.

Recommend Knowledge • Enable suggested articles so that when a new case is saved,
Resolve cases more quickly by surfacing recommended the search engine automatically looks for articles that have
knowledge articles based on key service request characteristics. keywords in common with the admin-selected case fields.

Skills Management • Align to a skills matrix for each service agent group.
Train agents as new products and services are introduced. • Outline which skills are needed for each tier, product, and
service.
• Require training and certifications for each service tier.
• Allow Omni-Channel to route cases to agents or queues with
the right skills within a defined queue.

Data Governance • To ensure quality, availability, and compliance, strengthen data

Deliver positive customer experiences by managing data assets governance.
and usage in accordance with organizational policy and • Support testing, marketing measurement, and sentiment
relevant regulations, including data stewardship, quality, analysis by implementing a single view of the customer.
integrity, privacy, and security.
• Give business users access to data and insights so that they
can base decisions on facts.
• Make decisions using customer-centric key performance
indicators, such as customer satisfaction, net promoter score,
and customer lifetime value.
• Grant all internal stakeholders insight into product usage and
performance. Provide customer stakeholders with proactive
insights.
• Develop a comprehensive, policy-oriented governance
framework that ensures on-time delivery of business
capabilities at the metadata level and APIs across all systems
and processes.

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Customer 360 Guide for Healthcare Payers Transform the Healthcare Payer Service Experience

CAPABILITY BEST PRACTICES

• To capture all business process and data flows, connect

corporate, market, and business teams’ data with back-office
infrastructure and call centers.
• Create an omni-channel journey for segments, contact groups,
values, and region with product strategy and mix.
• Integrate IT and business operations so that they function as
one team focused on customer success.
• Organize teams around desired outcomes, not functional roles
or silos in systems.
• Follow a documented process to gather, interpret, and share
all insights and product- and service-related data.

Compliance and Risk Mitigation • Set up a customer-centric framework for how the organization
Ensure that solutions meet corporate compliance requirements, operates and makes decisions that improve goal alignment,
and mitigate risk by establishing a set of policies and mitigate business risk, and maintain compliance to deliver
procedures that all teams understand and follow. solutions with speed.
• Design a flexible path forward to implement a governance
framework that includes operating procedures and guardrails
that ensure and maintain customer trust.
• Create a comprehensive guidebook to shrink operational silos
and promote distribution of responsibilities and scale.

Enable Agents to Handle Provider Inquiries in Health Cloud

Improve interactions with providers to help them better handle care requests and manage member health. Give providers tools to
manage their network and understand member benefits. Provide current provider information in member searches.

Solutions
Beginning
• Understand the Utilization Management Data Model
• Handle Care Requests with Utilization Management
• Set Up Data for Provider Search
• Flow Builder for Service
• Service Cloud Routing
Intermediate
• Provider Network Management for Health Cloud
• Automate Your Business Processes
• Connect to Claims Data
Advanced
• Connect to a Benefit Verification Service

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Customer 360 Guide for Healthcare Payers Transform the Healthcare Payer Service Experience

• Provider Network Management

• Use Mulesoft to Integrate with Salesforce

Capabilities

CAPABILITY BEST PRACTICES

Unified Agent Experience Approach • Integrate all support channels. Provide access using an
Improve customer satisfaction by smoothing agent-customer integrated interface that keeps information in context, smooths
interactions, even when customers move from one agent to interactions, and reduces repetition.
another. Deliver proactive, contextual information in a unified • Provide agents with relevant customer context so they can
way that empowers agents and reduces effort. provide the best service. Equip agents with tools for effective
collaboration with other teams, such as case swarming ability.
• Empower agents to gather and build on collective knowledge
to improve the knowledge base and self-service outcomes.
• Employ skills-based routing of cases to match customer
requests with agents who have the most suitable skills.
• Measure and improve the entire customer experience using
support data and customer analytics.

Case Notifications • Implement a system that allows for building, testing, and
Notify customers of key milestones as their service request releasing valuable system features with greater speed and
progresses. frequency while maintaining quality.
• Provide agents with a single source of truth for all case and
case collaboration data.
• Employ system administrations at scale, using employees’ or
customers’ preferred channels.

Case Notifications • Implement a system that allows for building, testing, and
Notify customers of key milestones as their service request releasing valuable system features with greater speed and
progresses. frequency while maintaining quality.
• Provide agents with a single source of truth for all case and
case collaboration data.
• Employ system administrations at scale, using employees’ or
customers’ preferred channels.

Case Management Approach • Create and define queue priority, and align business operations
Manage a service request from initiation through resolution, and IT with the case routing process.
including routing and assignment, ownership, traceability, and • Define case record types and support processes.
related interactions.
• Set up Email-to-Case and Web-to-Case.
• Add an actions and recommendations Lightning component
to the Lightning Service Console or other case record page
layouts.
• Set up a dashboard that surfaces a team’s cases by status for
a manager.

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CAPABILITY BEST PRACTICES

• Set the organization that’s aligned to actions associated with

lifecycle stages.
• Create escalation rule criteria, and sort rules from most complex
to least complex.
• Define business hours.
• Define escalation actions. When a case escalates, you can send
it to a different queue or user, and you can send an email that
notifies the case owner or others.
• Create email templates that notify users when a case escalates,
and include quick actions.
• Set up macros to let service agents respond quickly to
customers in a structured way.
• Create email templates for case open, case close, and a case
that escalates. Communication is key to ensuring a better
customer satisfaction (CSAT) score.
• Understand, track, and resolve customer service needs and
questions that align with priorities and affect strategic business
value.

Case Routing and Assignment • Align business operations and IT with the case routing process.
Assign ownership of service requests based on type of request, • Define case record types.
relevant agent skills, availability, and equitable distribution
• Define support processes.
based on agent performance goals.
• Create and define queue priority.
• Set up Email-to-Case and Web-to-Case.
• Categorize and triage service requests early for accurate
handling.
• Escalate request resolution based on priority and service level
agreement (SLA) expectations.
• Relate multi-channel correspondence and resolution notes to
the case lifecycle automatically to increase productivity.
• Use assignment rules to automate service request assignment.
• Use omni-channel routing to automatically match cases to the
agent with the best skills to solve them.
• Allow higher-maturity customers to route service requests
directly to agents based on relevant expertise and availability.

Solutions for Transforming the Healthcare Payer Experience

These solutions support capabilities within the Transform the Healthcare Payer Experience business scenario in the Customer 360 Guide
for Healthcare Payers. For details about capabilities tied to these solutions, review each business scenario separately.

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Customer 360 Guide for Healthcare Payers Transform the Healthcare Payer Service Experience

Enable Agents with a Holistic Member View

Learn more and review capabilities for this area.
Beginning
• Get to Know the Health Cloud Console
• Display a Patient’s Life Events
• Set Up Social Determinants to Assist High-Risk Patients and Members
• Customize the Timeline View
• Customize Patient Card Data
• Customize Patient Data Displays
• Learn to Customization Page Layouts
• Take a Look at the Household Data Model
Intermediate
• Use Mulesoft to Integrate with Health Cloud
• Interoperability and the Clinical Data Model
Advanced
• Salesforce Integration: Guide to Healthcare Interoperability (white paper)
• MuleSoft Accelerator for Healthcare

Handle Inquiries Consistently and Efficiently

Learn more and review capabilities for this area.
Beginning
• Increase Your Productivity in the Service Console
• Flow Builder for Service
• Service Cloud Routing
• Get to Know Health Cloud Console
Intermediate
• Flows
• Flow Builder for Service
• Salesforce Knowledge
• Salesforce Knowledge Help and Resources
• Entitlements
Advanced
• Digitize Document Management with Intelligent Document Automation
• Service Agent Scripts for Salesforce Flow
• Transcribe Calls with API
• Create Transcripts During a Call
• Working with Call Transcripts
• Let Customers Request that Support Get Back to Them

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Customer 360 Guide for Healthcare Payers Transform the Healthcare Payer Service Experience

Resources
• Shield Learning Map

Manage Sales, Administration, and Enrollment Inquiries

Learn more and review capabilities for this area.
Beginning
• Increase Productivity in Console
• Flow Builder for Service
• Set Up and Use Quick Text
Intermediate
• Design Your Quick Text Strategy
• Salesforce Knowledge
• Set Up Salesforce Knowledge
• Lightning Knowledge Setup and Customization
Advanced
• Digitize Document Management with Intelligent Document Automation

Resolve Member Plan and Care Related Inquiries and Follow-Ups

Learn more and review capabilities for this area.
Beginning
• Care Request Lightning Page
• Handle Care Requests
• Configure and Customize Care Request
• Enable Users to Verify Patient Benefits
• Health Cloud Provider Relationships and Search
• Enable Provider Search
Intermediate
• Set Up Utilization Management
• Install the Claims Data Model
• Connect to Claims Data
• Set Up Provider Relationship Cards
• Configure Provider Search
Advanced
• Medication Management

Handle Member Plan Transactions

Learn more and review capabilities for this area.

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Customer 360 Guide for Healthcare Payers Transform the Healthcare Payer Service Experience

Beginning
• Take a Look at the Household Data Model
• Manage Your Patients and Members Households
• Health Cloud Provider Relationships and Search
• Enable Provider Search for Users
Intermediate
• Connect to Claims Data
Advanced
• Support Intelligent Document Automation
• Use Intelligent Document Automation
• Mulesoft Accelerators for Healthcare

Provide Proactive and Prescriptive Member Service

Learn more and review capabilities for this area.
Beginning
• Einstein Next Best Action (documentation)
• Einstein Next Best Action (Trailhead module)
• Enable Care Team Gaps
Intermediate
• Recommendation Automation with Einstein Next Best Action
• Put Predictions into Action with Next Best Action
Advanced
• Manage Patient Risk with Analytics for Health Cloud: Risk Stratification

Engage Members During the Quote to Card Journey

Learn more and review capabilities for this area.
Beginning
• Email Marketing Best Practices
• Email Design Toolkit
• Manage Campaigns with Health Cloud
Intermediate
• Getting Started: Marketing Cloud: Data and Segmentation Basics
• Getting Started with Marketing Cloud Email Studio
• Manage Customer Journeys
• Audience Segmentation
Advanced
• Advanced Customer Journeys

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Customer 360 Guide for Healthcare Payers Transform the Healthcare Payer Service Experience

Enable Self-Service for Members

Learn more and review capabilities for this area.
Beginning
• The Importance of Self-Service Portals
• Experience Cloud Sites for Healthcare
• Set Up an Experience Cloud Site
• Understand the Basics of Experience Cloud
• Configure Your Self-Registration Page
• Learn About Einstein Bots Compliance
• What is a Chatbot
• Chat with Your Customers on Your Website
Intermediate
• Secure Your Experience Cloud Site
• Enable Cases for Experience Cloud Site
• Add a Flow to an Experience Builder Site
• Customize Your Chat Implementation
• Setup Chat with a Guided Flow
Advanced
• Improve Experience Cloud Site Performance
• Configure Search Functionality in Experience Cloud
• Manage Your Community Email Notifications
• Data Model for Peer to Peer Conversations in Experience Cloud
• Einstein Bots

Manage Contact Center Operations

Learn more and review capabilities for this area.
Beginning
• Analyze Your Service Data in Salesforce
• Get Insights from Your Health Cloud Data with CRM Analytics
• Set Up a Customer Feedback Survey
Intermediate
• Set Up CRM Analytics for Healthcare
• Set Up Omni Supervisor
Advanced
• Workforce Engagement
• Focus on Training
Resources
• Service & Supports Dashboards Package

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Customer 360 Guide for Healthcare Payers Personalize Care in Healthcare Payer Organizations

• Preconfigured Service Cloud Dashboards

• Omni Channel Performance Dashboard

Enable Agents to Handle Provider Inquiries

Learn more and review capabilities for this area.
Beginning
• Understand the Utilization Management Data Model
• Handle Care Requests with Utilization Management
• Set Up Data for Provider Search
• Flow Builder for Service
• Service Cloud Routing
Intermediate
• Provider Network Management for Health Cloud
• Automate Your Business Processes
• Connect to Claims Data
Advanced
• Connect to a Benefit Verification Service
• Provider Network Management
• Use Mulesoft to Integrate with Salesforce

Personalize Care in Healthcare Payer Organizations

Foster member and patient well-being with an approach to care that connects services and care management.
With personalized care, payers guide members on the journey most likely to lead to improved health and well-being. Developing a
complete view of the members’ health status, provider or interdisciplinary care team, social determinants, preferences, and motivations
helps to deliver better care.
Providing personalized care allows payers to:
• Control conditions and influence healthier outcomes by proactively identifying high-risk members with intelligent risk segmentation
and assigning them to personalized care programs.
• Enroll members into personalized care programs and manage wellness incentives.
• Gain actionable insights with a complete view of the member by unlocking data from legacy and claims systems.
• Engage the entire care team with digital member access through secure sites and real-time collaboration between members and
providers, accessible on any channel and any device.
• Enable member and provider self-service on a digital portal using the same processes from the internal care management console.

Success Metrics
Tracking key performance indicators (KPIs) helps you monitor the success of your changes.
Business KPIs
Business KPIs usually track revenue increases and cost reductions.
• Reduced gaps in care

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Customer 360 Guide for Healthcare Payers Personalize Care in Healthcare Payer Organizations

• Reduced social determinants of health (SDOH) barriers

• Improved care plan adherence
• Improved clinical outcomes
• Decreased cost of care
• Improved member retention
• Improved provider satisfaction
Process KPIs
Data to support process KPI metrics can be pulled from Salesforce reports.
• Increased percentage of members eligible enrolled in programs
• Increased percentage of members enrolled that completed
• Increased percentage of members actions completed
• Increased percentage of members reached that are eligible for a program
• Increased number of members completing health assessment
• Increased percentage of medication reviews completed

Products
These products can help you personalize care.
• Health Cloud
• Marketing Cloud
• Experience Cloud
• Platform
• Shield
• Tableau
• CRM Analytics
• Einstein
• Mulesoft (optional)

Business Capabilities
To create positive customer experiences while increasing organizational efficiency, implement technical solutions and best practices
that can enhance your business capabilities.

Access a Holistic Member View

Provide a 360-degree view of each member, including patient data and life events, using integrated and synchronized data sources.
Monitor member touchpoints to enhance collaborative care.
Handle Member Inquiries in Health Cloud
Use skill-based routing to provide superior customer service. Understand the next best action when wrapping up calls.
Collaborate with Members on a Self-Service Portal
Provide members with the ability to find the information and answers that they need in a self-service portal.

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Engage Members Throughout the Care Journey

Enhance member care and improve health outcomes by personalizing care planning, communicating with members throughout
their care journey, and engaging each member’s support system.
Establish Care Programs for Members
Set up care plans, and onboard new members.
Find Specialists to Manage Member Health
Partner with providers, and manage provider relationships.
Manage Member Health with Rewards and Recommendations
Enhance product and benefits recommendations with analytics. Manage member loyalty.
Manage Member Medication and Care Requests
Manage medications and medication cost containment.
Manage Population Health
Segment members into logical cohorts to better understand needs, inform customer experience strategy, and align support strategies.
Provide a care management dashboard.
Monitor Member Experience
Collect and evaluate member feedback to understand your members’ experience.
Provide Personalized Care Guidance
Integrate care planning with evidence-based guidelines, and provide clinical and non-clinical assessments. Create and apply care
plans with goals, provide follow-up with care coaches, and monitor adherence to the plan. Integrate data from intelligent devices.
Solutions for Personalizing Care
These solutions support capabilities within the Personalize Care in Healthcare Payer Organizations business scenario in the Customer
360 Guide for Healthcare Payers. For details about capabilities tied to these solutions, review each business scenario separately.

SEE ALSO:
Business Scenarios for Healthcare Payers
Salesforce Business Scenarios: Quick Look

Access a Holistic Member View

Provide a 360-degree view of each member, including patient data and life events, using integrated and synchronized data sources.
Monitor member touchpoints to enhance collaborative care.

Solutions
Beginning
• Customize Patient Card Data
• Customize Patient Data Displays
• Get to Know the Health Cloud Console
• Display a Patient’s Life Events
• Set Up Social Determinants to Assist High-Risk Patients and Members
• Customize a Timeline View

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Customer 360 Guide for Healthcare Payers Personalize Care in Healthcare Payer Organizations

Intermediate
• Omni-Channel Supervisor
• Monitor Your Contact Center with Omni-Channel Supervisor
• Healthcare Integration with Mulesoft
• Interoperability and the Clinical Data Model
Advanced
• MuleSoft Accelerator for Healthcare
• Salesforce Integration: Guide to Healthcare Interoperability (white paper)
• Power the next generation of healthcare innovation (thought leadership)

Capabilities

CAPABILITY BEST PRACTICES

Research and Design Practice • Align people, processes, technology, and data around delivery
To inform products, services, marketing, and process design, of thoughtfully designed customer and employee journeys.
set up a group of experts to examine what users want and • Have cross-functional teams across design, strategy, and
need. operations collect feedback from customers, employees,
partners, communities, and shareholders.
• Encourage rapid and continuous delivery by establishing lean
governance, human-led approaches to change, open lines of
communication, and agility to make changes as needed.
• Create an environment where business lines and IT work
together to determine how technology can drive business
goals.
• Encourage conscious efforts to improve communication,
collaboration, and cooperation with a common vision for the
free flow of information, collaboration tools, and
cross-functional teams.

Modern Architecture Approach • Aggregate structured and unstructured data about each
All business lines involved in the customer journey have a full customer from across the organization for a unified customer
enterprise view of each customer, including profile, preferences, view.
products, and services. • Use the unified customer view that includes segment data to
build personalized interactions for every customer regardless
of where the interaction happens.

Single View of the Customer • Identify the most critical data sources based on customer
Align relevant data sources at the individual customer level to lifecycle stages and moments that matter, prioritizing the top
support customer-centric marketing efforts. 3–5 customer journeys. Use the top journeys to inform business
requirements for data alignment or integration work.
• Create a data model with primary and secondary customer ID
fields and keys.

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CAPABILITY BEST PRACTICES

• Deploy an identity solution to connect users across devices

using deterministic and probabilistic approaches.
• Add secondary priority data sources.

Data Governance • To ensure quality, availability, and compliance, strengthen data

Deliver positive customer experiences by managing data assets governance.
and usage in accordance with organizational policy and • Support testing, marketing measurement, and sentiment
relevant regulations, including data stewardship, quality, analysis by implementing a single view of the customer.
integrity, privacy, and security.
• Give business users access to data and insights so that they
can base decisions on facts.
• Make decisions using customer-centric key performance
indicators, such as customer satisfaction, net promoter score,
and customer lifetime value.
• Grant all internal stakeholders insight into product usage and
performance. Provide customer stakeholders with proactive
insights.
• Develop a comprehensive, policy-oriented governance
framework that ensures on-time delivery of business
capabilities at the metadata level and APIs across all systems
and processes.
• To capture all business process and data flows, connect
corporate, market, and business teams’ data with back-office
infrastructure and call centers.
• Create an omni-channel journey for segments, contact groups,
values, and region with product strategy and mix.
• Integrate IT and business operations so that they function as
one team focused on customer success.
• Organize teams around desired outcomes, not functional roles
or silos in systems.
• Follow a documented process to gather, interpret, and share
all insights and product- and service-related data.

Third-Party Integration Management • Monitor, add, edit, and track the ingestion flow from data flows
Manage performance, ROI, best practices, and process like systems of record, reference, and engagement.
improvements. • Align high-level stakeholders from business, operations, and
IT. Be aware of app-centric solution reference architecture.
Combine the architecture with a governance and planning
process for enterprise architecture-mapping diagrams.
• Align and share solution patterns, data flows, and governance
model playbooks from the same data set. Include engagement
and activity updates for program management.

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• Encourage the use of periodic refreshes, at least one time per

quarter, to ensure alignment with operations and business
lines.
• Enable individuals outside of sales to communicate changes
in design patterns and data accuracy for distributed leadership.
Own each business line and the operational systems of
reference, engagement, and record.
• Use relationship management to reflect key individual
dynamics within the distributed application data flows for
ingestion.

Chat Channel • Identify priority chat channels, and locations and products to
Provide an engaging and personalized shopping experience deploy chat.
by connecting customers with the right person for guidance • Organize your content to align to the right channels.
and advice.
• Establish operations and strategic key performance indicators.
• Enable chat.
• Set up request routing.
• Specify a location for chat.
• Determine what records to link to chat.
• Create an offline form option.
• Deploy chat to relevant pages.

Handle Member Inquiries in Health Cloud

Use skill-based routing to provide superior customer service. Understand the next best action when wrapping up calls.

Solutions
Beginning
• Service Cloud Routing
• Einstein Next Best Action
• Einstein Next Best Actions Considerations
Intermediate
• Omni-Channel for Lightning Experience
• Understand Skills-Based Routing
• Get Started with Einstein Next Best Action

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Capabilities

CAPABILITY BEST PRACTICES

Case Management Approach • Create and define queue priority, and align business operations
Manage a service request from initiation through resolution, and IT with the case routing process.
including routing and assignment, ownership, traceability, and • Define case record types and support processes.
related interactions.
• Set up Email-to-Case and Web-to-Case.
• Add an actions and recommendations Lightning component
to the Lightning Service Console or other case record page
layouts.
• Set up a dashboard that surfaces a team’s cases by status for
a manager.
• Set the organization that’s aligned to actions associated with
lifecycle stages.
• Create escalation rule criteria, and sort rules from most complex
to least complex.
• Define business hours.
• Define escalation actions. When a case escalates, you can send
it to a different queue or user, and you can send an email that
notifies the case owner or others.
• Create email templates that notify users when a case escalates,
and include quick actions.
• Set up macros to let service agents respond quickly to
customers in a structured way.
• Create email templates for case open, case close, and a case
that escalates. Communication is key to ensuring a better
customer satisfaction (CSAT) score.
• Understand, track, and resolve customer service needs and
questions that align with priorities and affect strategic business
value.

Case Routing and Assignment • Align business operations and IT with the case routing process.
Assign ownership of service requests based on type of request, • Define case record types.
relevant agent skills, availability, and equitable distribution
• Define support processes.
based on agent performance goals.
• Create and define queue priority.
• Set up Email-to-Case and Web-to-Case.
• Categorize and triage service requests early for accurate
handling.
• Escalate request resolution based on priority and service level
agreement (SLA) expectations.
• Relate multi-channel correspondence and resolution notes to
the case lifecycle automatically to increase productivity.
• Use assignment rules to automate service request assignment.

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• Use omni-channel routing to automatically match cases to the

agent with the best skills to solve them.
• Allow higher-maturity customers to route service requests
directly to agents based on relevant expertise and availability.

Scheduling and Workforce Optimization Approach • To understand their current process and deliverables to service
Balance customer satisfaction, service levels, workforce operations, engage with the workforce management (WFM)
scheduling, operational costs, and other key performance team.
metrics to maximize employees’ time. • Review the current scheduling process and outputs, such as
agent schedule.
• Understand calculations that determine how many agents are
needed, based on:
– Service level and speed of answer (80/20 or 80/30)
– Productivity and how it’s calculated (occupancy and
utilization)
– The cost to service compromise
– Erlang calculations used for staffing needs
– The relationship between contact center, skill group size,
and efficiency

• Determine usage of the Erlang Calculator tool for scheduling.

What is the number of calls expected over a time period? For
example, per half hour. What’s the average handling time?
What’s the service level, target answer time, maximum
occupancy, and shrinkage? The calculator uses these details
to calculate the number of advisors required to handle the
expected call volumes over the reporting period. The calculator
gives exact figures for service level and occupancy to account
for decimal point numbers.
• Review real-time reports generated for adherence and
variations.
• Understand operations team processes for managing real-time
spikes, service level adherence, and performance management.
• Analyze data that can help track causes of unexpected spikes
in contacts volumes.
• Assess how to manage attendance and adherence to
schedules.
• Understand reaction strategy, including any service disruption
strategy in place.
• Schedule a business continuity plan (BCP) review. Ensure that
the BCP is an all-encompassing document that identifies any
type of disaster, the impact of that disaster, and the recovery
procedures. The likelihood of disasters varies by location.

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Next Best Action • Use AI to predict, detect, profile, and classify cases across the
Provide proactive recommendations to service agents on what customer service organization.
to do next based on customer and industry data and built-in • Relate multi-channel correspondence and resolution notes to
business logic. Use AI to predict, detect, profile, and classify the case lifecycle automatically to increase productivity.
cases across the customer service organization.
• Use customer context and AI to recommend knowledge.
Recommend articles based on relevance to the request they’re
working on.

Collaborate with Members on a Self-Service Portal

Provide members with the ability to find the information and answers that they need in a self-service portal.

Solutions
Beginning
• Experience Cloud Setup Checklist
Intermediate
• Manage Your Site’s Pages and Their Properties in Experience Builder
• Build an Experience Cloud Site with Knowledge and Chat

Capabilities

CAPABILITY BEST PRACTICES

Knowledge Management Approach • Align on the article lifecycle stages and actions associated with
Capture and distribute reusable, relevant, and accurate each stage. Common stages are draft, review, approve, publish,
knowledge content across one or more channels internally and archive.
and externally to customers and partners. • Identify owners for each stage of the lifecycle and approval
process by article type or data category.
• Identify subject matter experts who can write articles about
your products and services.
• Enable Email-to-Case so that agents can send articles to
customers.
• To help track individual, group, and organizational article
quality trends and effectiveness over time, install the Article
Quality Index managed package from AppExchange.
• Install the Knowledge Article Feedback managed package from
AppExchange.
• To help find and classify articles, questions, or ideas, define
data categories.
• Enable feed tracking on knowledge articles and tagging on
knowledge articles.

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• Add an actions and recommendations Lightning Web

Component to the case page layout or console layout.
• Ensure that case titles are accurate, clear, and follow the
structure defined by the business or IT.
• Decide which languages you want to translate in-house versus
sending articles to a localization vendor. If there are at least
three languages, ensure that there’s a version management
process in place for all translated articles.
• Ensure that communications go out to team members involved
in the knowledge lifecycle process.
• To help find and classify articles, questions, or ideas, define
data categories.
• Define article record types.
• Enable feed tracking on knowledge articles.
• Enable tagging on knowledge articles.
• Ensure that articles are rated so that agents can get an
understanding of how effective the article is.

Engage Members Throughout the Care Journey

Enhance member care and improve health outcomes by personalizing care planning, communicating with members throughout their
care journey, and engaging each member’s support system.

Solutions
Beginning
• Email Marketing Best Practices
• Engage the Patient’s Supporters to Customize and Coordinate Care
• Email Design Toolkit
• Manage Campaigns with Health Cloud
Intermediate
• Getting Started: Marketing Cloud: Data and Segmentation Basics
• Getting Started with Email Studio
• Manage Customer Journeys
Advanced
• Advanced Customer Journeys
Thought Leadership
• Enhance Patient and Member Engagement Guide

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Capabilities

CAPABILITY BEST PRACTICES

Single View of the Customer • Identify the most critical data sources based on customer
Align relevant data sources at the individual customer level to lifecycle stages and moments that matter, prioritizing the top
support customer-centric marketing efforts. 3–5 customer journeys. Use the top journeys to inform business
requirements for data alignment or integration work.
• Create a data model with primary and secondary customer ID
fields and keys.
• Deploy an identity solution to connect users across devices
using deterministic and probabilistic approaches.
• Add secondary priority data sources.

Lifecycle Marketing • Define the lifecycle by industry or organization. A basic lifecycle

Tailor marketing messages based on each stage of the consists of awareness, acquisition, onboarding, engagement,
customer’s lifecycle. and retention.
• Define customer needs and moments that matter to customers
at each stage of the lifecycle.
• Develop a well-defined customer lifecycle, and use it to
orchestrate messages across touchpoints.
• Use analytics to place contacts, leads, prospects, or customers
in a lifecycle stage.
• Develop a set of tactics for each stage of the lifecycle that
addresses customer needs and company goals. For example,
assign lapsed customers a win-back campaign when they
haven’t opened or clicked an email in the past 6 months.
• To orchestrate the correct messages and channels in each
lifecycle stage, build automations and audience segmentation
activities.
• Implement a dynamic system that can move customers
through the current lifecycle stages and into new stages.
• Coordinate channels. Use personalization to engage customers
at each stage of the lifecycle.
• To create experiences that are lifecycle-driven, build customer
capabilities.

Account Segmentation Approach • Align segmentation to the organization’s wider business goals.
Define, prioritize, and combine segment attributes. Group • Ask sales, marketing, service, the business unit, and other key
accounts to support business goals. leaders to define the overarching business goals.
• Let sales leaders derive objectives that support business goals.
• Ask sales leaders and sales operations to identify key attributes
that help profile accounts. Use qualitative and quantitative
data, such as industry, number of employees, and future
revenue potential.

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• Combine multiple attributes for a well-rounded segmentation

approach.

Customer Segmentation for Service • Segment customers by demographics, behavior, geography,

Align corporate customer segmentation models to determine benefit, customer journey, or other relevant qualities.
service support and channel strategies. • Create customer profiles that provide useful information and
context for each customer.
• Tailor customer support experiences based on customer
segment. For example, target specific customer segments for
more or less personalized service based on spend or value.
• Address concerns before they arise, and make every customer
service interaction special.

Journey Design • Identify marketing objectives, campaigns to support each

Use a consistent approach to the design and development of objective, audience targeting requirements, data variables, and
customer journeys across all channels and stages of the attributes needed. Map where and how to source this
customer lifecycle. information. Use a journey design roadmap.
• To identify customer lifecycle and moments that matter, hold
a cross-functional workshop. Workshop journeys for four types
of moments that matter. For each journey, define a goal,
audience, data needs, content, and channels.
• Identify the content based on two types. In-journey content
is the delivered message that can be consumed without leaving
the inbox or screen. Outside-journey content includes the
resources that the customer navigates to with a click or tap,
such as web content.
• Prioritize journeys based on evaluation criteria, and create a
journey backlog.
• Design a simple, single-channel journey to start. For example,
a welcome email triggered by registration or conversion event.
• Evolve journeys to multiple channels, connecting multiple
journeys.
• Incorporate experience design principles in journeys.

Direct Marketing • Evaluate each message at the customer level to determine

Use owned and operated channels and platforms, including whether to send it.
direct mail, email, events, mobile apps, social platforms, and • Use messages to extend customer journeys based on
websites to deliver highly coordinated, personalized marketing engagement.
messages.
• Personalize messages at the segment level using dynamic
content, and at the subscriber level using personalization
strings.
• Use templates within Content Builder so that marketers can
modify content without technical support.

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• Use media queries and responsive design to optimize mobile

and desktop experiences to drive higher engagement.
• Use interactive email to drive engagement and conversion and
collect more first-party data.

Behavioral Email Strategy • Understand on-site customer behavior to identify opportunities

Define and manage behavioral emails, including segmenting, for behavioral emails. For example, when a customer abandons
targeting, AI, and content. a search, cart, or product description page.
• Create email journeys for a defined strategy.
• Define benchmarks and key performance indicators to measure
success.
• Deploy and regularly test to validate benchmarks and key
performance indicators.

Campaign Planning • Align on company business goals and key performance

Work across departments to define and align on campaign indicators.
and promotion strategy. • Ensure consistent experiences by defining campaign planning
across all channels.

Channel Strategy Approach • Tie channel service strategy to the overall service strategy. For
Plan an approach for handling service requests from multiple example, if customer service is the primary goal, determine
channels. what level of service, channels, and options to make available
by customer segment.
• Determine the ideal channels for customers to engage with
customer service. These channels meet customer needs with
the least amount of friction. Align this channel strategy with
the service strategy.
• Ensure that a strategy is in place to support these channels.
• Use customer segmentation models to drive specific customer
types to specific channels.

Customer Communities • Determine the set of documents and tools to share with
Create and maintain communities in which you can collaborate channel partners.
with your customers on a unified platform to create • Provide channel partners with collaborative documents for
customer-specific sales agreements and joint business plans. sales agreements.
• Add joint business planning.
• Launch a community portal with secure logins for channel
partners to collaborate. Provide the ability to post or upload
key information.

Self-Service Adoption • Formalize your business process, and carry it through to the
Monitor customers’ use of virtual self-service. Empower portal. For example, give agents access to the same FAQs as
customers to resolve self-service requests. Let service agents your customers.

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and customers work across the business with digital • Identify your self-service users, and define the member
engagement across channels. experience.
• Create solutions that answer commonly asked questions.
• Decide how to notify your users about the self-service portal.

Chat Channel • Identify priority chat channels, and locations and products to
Provide an engaging and personalized shopping experience deploy chat.
by connecting customers with the right person for guidance • Organize your content to align with the right channels.
and advice.
• Establish operations and strategic key performance indicators.
• Enable chat.
• Set up request routing.
• Specify a location for chat.
• Determine what records to link to chat.
• Create an offline form option.
• Deploy chat to relevant pages.

Establish Care Programs for Members

Set up care plans, and onboard new members.

Solutions
Health Cloud care plans combine the Service Cloud case model with a care plan record type and added functionality.
Beginning
• Health Cloud Care Plans
• Set Up Care Plans
• Create and Use Care Plans
• Care Plan Templates Help Simplify Onboarding
• Provide Assessments for Gathering Information
• Service Cloud Agent Experience
• Manage and Work with Cases
Intermediate
• Set Up Case Escalation and Entitlements

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Capabilities

CAPABILITY BEST PRACTICES

Journey Design • Identify marketing objectives, campaigns to support each

Use a consistent approach to the design and development of objective, audience targeting requirements, data variables, and
customer journeys across all channels and stages of the attributes needed. Map where and how to source this
customer lifecycle. information. Use a journey design roadmap.
• To identify customer lifecycle and moments that matter, hold
a cross-functional workshop. Workshop journeys for four types
of moments that matter. For each journey, define a goal,
audience, data needs, content, and channels.
• Identify the content based on two types. In-journey content
is the delivered message that can be consumed without leaving
the inbox or screen. Outside-journey content includes the
resources that the customer navigates to with a click or tap,
such as web content.
• Prioritize journeys based on evaluation criteria, and create a
journey backlog.
• Design a simple, single-channel journey to start. For example,
a welcome email triggered by registration or conversion event.
• Evolve journeys to multiple channels, connecting multiple
journeys.
• Incorporate experience design principles in journeys.

Behavioral Email Strategy • Understand on-site customer behavior to identify opportunities

Define and manage behavioral emails, including segmenting, for behavioral emails. For example, when a customer abandons
targeting, AI, and content. a search, cart, or product description page.
• Create email journeys for a defined strategy.
• Define benchmarks and key performance indicators to measure
success.
• Deploy and regularly test to validate benchmarks and key
performance indicators.

Modern Architecture Approach • Aggregate structured and unstructured data about each
All business lines involved in the customer journey have a full customer from across the organization for a unified customer
enterprise view of each customer, including profile, preferences, view.
products, and services. • Use the unified customer view that includes segment data to
build personalized interactions for every customer regardless
of where the interaction happens.

Find Specialists to Manage Member Health

Partner with providers, and manage provider relationships.

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Solutions
Beginning
• Health Cloud Provider Relationships and Search
• Help Patients to Connect with Providers
Intermediate
• Set Up Data for Provider Search (help article)
• Set Up Data for Provider Search (developer guide)

Capabilities

CAPABILITY BEST PRACTICES

Self-Service Adoption • Formalize your business process, and carry it through to the
Monitor customers’ use of virtual self-service. Empower portal. For example, give agents access to the same FAQs as
customers to resolve self-service requests. Let service agents your customers.
and customers work across the business with digital • Identify your self-service users, and define the member
engagement across channels. experience.
• Create solutions that answer commonly asked questions.
• Decide how to notify your users about the self-service portal.

Manage Member Health with Rewards and Recommendations

Enhance product and benefits recommendations with analytics. Manage member loyalty.

Solutions
Beginning
• Enable Care Teams to Track Gaps
• Einstein Next Best Action
• Get Started with Einstein Next Best Action
Intermediate
• Get Started with Loyalty Management

Capabilities

CAPABILITY BEST PRACTICES

Single View of the Customer • Identify the most critical data sources based on customer
Align relevant data sources at the individual customer level to lifecycle stages and moments that matter, prioritizing the top
support customer-centric marketing efforts. 3–5 customer journeys. Use the top journeys to inform business
requirements for data alignment or integration work.
• Create a data model with primary and secondary customer ID
fields and keys.

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• Deploy an identity solution to connect users across devices

using deterministic and probabilistic approaches.
• Add secondary priority data sources.

Direct Marketing • Evaluate each message at the customer level to determine

Use owned and operated channels and platforms, including whether to send it.
direct mail, email, events, mobile apps, social platforms, and • Use messages to extend customer journeys based on
websites to deliver highly coordinated, personalized marketing engagement.
messages.
• Personalize messages at the segment level using dynamic
content and at the subscriber level using personalization
strings.
• Use templates within Content Builder so that marketers can
modify content without technical support.
• Use media queries and responsive design to optimize mobile
and desktop experiences to drive higher engagement.
• Use interactive email to drive engagement and conversion and
collect more first-party data.

Experience Design • Conduct user-focused design research.

The process of shaping brand interactions based on an • Define user goals in customer-centric language.
understanding of user behavior and expectations. Apply
– Use empathy to better understand users.
experience design principles to every marketing interaction,
message, and touchpoint. – Use human language, not system or tech-centric language.

• Consider the user’s context. For example, what location is the

customer in? Are they on the go, at their desk, using a kiosk,
or using a mobile device
• Gather feedback in a non-intrusive manner.
• Document and share findings from user-focused design
research with all business users, partners, and stakeholders.
• Formulate, socialize, distribute, and conduct enablement on
experience design principles and guidelines specific to your
brand.
• Ensure that marketing campaigns, journeys, messages, and
interactions reflect experience design principles.
• Build in feedback loops that enable users, employees, and
partners to comment on experiences.
• Revisit user-focused design. Research and update experience
design principles and guidelines.

Manage Member Medication and Care Requests

Manage medications and medication cost containment.

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Solutions
Beginning
• Medication Management
• Configure Patient Medication Manager
• Understand the Utilization Management Data Model
• Handle Care Requests with Utilization Management
Advanced
• Connect to a Benefit Verification Service

Capabilities

CAPABILITY BEST PRACTICES

Knowledge Management Approach • Align on the article lifecycle stages and actions associated with
Capture and distribute reusable, relevant, and accurate each stage. Common stages are draft, review, approve, publish,
knowledge content across one or more channels internally and archive.
and externally to customers and partners. • Identify owners for each stage of the lifecycle and approval
process by article type or data category.
• Identify subject matter experts who can write articles about
your products and services.
• Enable Email-to-Case so that agents can send articles to
customers.
• To help track individual, group, and organizational article
quality trends and effectiveness across time, install the Article
Quality Index managed package from AppExchange
• Install the Knowledge Article Feedback managed package from
AppExchange.
• To help find and classify articles, questions, or ideas, define
data categories.
• Enable feed tracking on knowledge articles and tagging on
knowledge articles.
• Add an actions and recommendations Lightning Web
Component to the case page layout or console layout.
• Ensure that case titles are accurate, clear, and follow the
structure defined by the business or IT.
• Decide which languages you want to translate in-house versus
sending articles to a localization vendor. If there are at least
three languages, ensure that there’s a version management
process in place for all translated articles.
• Ensure that communications go out to team members involved
in the knowledge lifecycle process.
• To help find and classify articles, questions, or ideas, define
data categories.

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• Define article record types.

• Enable feed tracking on knowledge articles.
• Enable tagging on knowledge articles.
• Ensure that articles are rated so that agents can get an
understanding of how effective the article is.

Single View of the Customer • Identify the most critical data sources based on customer
Align relevant data sources at the individual customer level to lifecycle stages and moments that matter, prioritizing the top
support customer-centric marketing efforts. 3–5 customer journeys. Use the top journeys to inform business
requirements for data alignment or integration work.
• Create a data model with primary and secondary customer ID
fields and keys.
• Deploy an identity solution to connect users across devices
using deterministic and probabilistic approaches.
• Add secondary priority data sources.

Modern Architecture Approach • Aggregate structured and unstructured data about each
All business lines involved in the customer journey have a full customer from across the organization for a unified customer
enterprise view of each customer, including profile, preferences, view.
products, and services. • Use the unified customer view that includes segment data to
build personalized interactions for every customer regardless
of where the interaction happens.

Manage Population Health

Segment members into logical cohorts to better understand needs, inform customer experience strategy, and align support strategies.
Provide a care management dashboard.

Solutions
Beginning
• Email Marketing Best Practices
• Engage the Patient’s Supporters to Customize and Coordinate Care
• Discover the Social Determinants of Health Data Model
Intermediate
• Manage Patient Risk with Analytics for Health Cloud: Risk Stratification
• Set Up Einstein Analytics for Health Cloud Risk Stratification
• Use Patient Segmentation and Social Determinants Dashboards
• Audience Segmentation
• Manage Customer Journeys

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Advanced
• Advanced Customer Journeys
• Get Insights from Your Health Cloud Data with CRM Analytics for Health Cloud
• Set Up the CRM Analytics for Healthcare App
Thought Leadership
• Enhance Patient and Member Engagement Guide
• How Healthcare CRM is Transforming Population Health
• Technology Enabled Population Health (video)

Capabilities

CAPABILITY BEST PRACTICES

Lifecycle Marketing • Define the lifecycle by industry or organization. A basic lifecycle

Tailor marketing messages based on each stage of the consists of awareness, acquisition, onboarding, engagement,
customer’s lifecycle. and retention.
• Define customer needs and moments that matter to customers
at each stage of the lifecycle.
• Develop a well-defined customer lifecycle, and use it to
orchestrate messages across touchpoints.
• Use analytics to place contacts, leads, prospects, or customers
in a lifecycle stage.
• Develop a set of tactics for each stage of the lifecycle that
addresses customer needs and company goals. For example,
assign lapsed customers a win-back campaign when they
haven’t opened or clicked an email in the past 6 months.
• To orchestrate the correct messages and channels in each
lifecycle stage, build automations and audience segmentation
activities.
• Implement a dynamic system that can move customers
through the current lifecycle stages and into new stages.
• Coordinate channels. Use personalization to engage customers
at each stage of the lifecycle.
• To create experiences that are lifecycle-driven, build customer
capability.

Account Segmentation Approach • Align segmentation to the organization’s wider business goals.
Define, prioritize, and combine segment attributes. Group • Ask sales, marketing, service, the business unit, and other key
accounts to support business goals. leaders to define the overarching business goals.
• Let sales leaders derive objectives that support business goals.
• Ask sales leaders and sales operations to identify key attributes
that help profile accounts. Use qualitative and quantitative

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data such as industry, number of employees, and future
revenue potential.
• Classify accounts by segment.
• Consider how segment attribute information is structured,
captured, and maintained to support account segmentation.
• Consider how to handle complex segmentation scenarios in
a consistent way across the business.
• Consider which of the other business capabilities are influenced
by or supported through account segmentation.
• Consider the sales team structure, and match it to the account
segments and tiers.
• Analyze the resources required to deliver the best servicing
approach.
• Consider the geography of the accounts.
• Allocate resources to the segments and tiers.
• Combine multiple attributes for a well-rounded segmentation
approach.

Customer Segmentation for Service • Segment customers by demographics, behavior, geography,

Align corporate customer segmentation models to determine benefit, customer journey, or other relevant qualities.
service support and channel strategies. • Create customer profiles that provide useful information and
context for each customer.
• Tailor customer support experiences based on customer
segment. For example, target specific customer segments for
more or less personalized service based on spend or value.
• Address concerns before they arise, and make every customer
service interaction special.

Research and Design Practice • Align people, processes, technology, and data around delivery
To inform products, services, marketing, and processes design, of thoughtfully designed customer and employee journeys.
set up a group of experts to examine what users want and • Have cross-functional teams across design, strategy, and
need. operations collect feedback from customers, employees,
partners, communities, and shareholders.
• Encourage rapid and continuous delivery by establishing lean
governance, human-led approaches to change, open lines of
communication, and agility to make changes as needed.
• Create an environment where business lines and IT work
together to determine how technology can drive business
goals.
• Encourage conscious efforts to improve communication,
collaboration, and cooperation with a common vision for the
free flow of information, collaboration tools, and
cross-functional teams.

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CAPABILITY BEST PRACTICES

Modern Architecture Approach • Aggregate structured and unstructured data about each
All business lines involved in the customer journey have a full customer from across the organization for a unified customer
enterprise view of each customer, including profile, preferences, view.
products, and services. • Use the unified customer view that includes segment data to
build personalized interactions for every customer regardless
of where the interaction happens.

Knowledge Management Approach • Align on the article lifecycle stages and actions associated with
Capture and distribute reusable, relevant, and accurate each stage. Common stages are draft, review, approve, publish,
knowledge content across one or more channels internally and archive.
and externally to customers and partners. • Identify owners for each stage of the lifecycle and approval
process by article type or data category.
• Identify subject matter experts who can write articles about
your products and services.
• Enable Email-to-Case so that agents can send articles to
customers.
• To help track individual, group, and organizational article
quality trends and effectiveness over time, install the Article
Quality Index managed package from AppExchange
• Install the Knowledge Article Feedback managed package from
AppExchange.
• To help find and classify articles, questions, or ideas, define
data categories.
• Enable feed tracking on knowledge articles and tagging on
knowledge articles.
• Add an actions and recommendations Lightning Web
Component to the case page layout or console layout.
• Ensure that case titles are accurate, clear, and follow the
structure defined by the business or IT.
• Decide which languages you want to translate in-house versus
sending articles to a localization vendor. If there are at least
three languages, ensure that there’s a version management
process in place for all translated articles.
• Ensure that communications go out to team members involved
in the knowledge lifecycle process.
• To help find and classify articles, questions, or ideas, define
data categories.
• Define article record types.
• Enable feed tracking on knowledge articles.
• Enable tagging on knowledge articles.
• Ensure that articles are rated so that agents can get an
understanding of how effective the article is.

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Monitor Member Experience

Collect and evaluate member feedback to understand your members’ experience.

Solutions
Beginning
• Design and Distribute Surveys with Salesforce Feedback Management

Capabilities

CAPABILITY BEST PRACTICES

Experience Design • Conduct user-focused design research.

The process of shaping brand interactions based on an • Define user goals in customer-centric language.
understanding of user behavior and expectations. Apply
– Use empathy to better understand users.
experience design principles to every marketing interaction,
message, and touchpoint. – Use human language, not system or tech-centric language.

• Consider the user’s context. For example, what location is the

customer in? Are they on the go, at their desk, using a kiosk,
or using a mobile device.
• Gather feedback in a non-intrusive manner.
• Document and share findings from user-focused design
research with all business users, partners, and stakeholders.
• Formulate, socialize, distribute, and conduct enablement on
experience design principles and guidelines specific to your
brand.
• Ensure that marketing campaigns, journeys, messages, and
interactions reflect experience design principles.
• Build in feedback loops that enable users, employees, and
partners to comment on experiences.
• Revisit user-focused design. Research and update experience
design principles and guidelines.

Provide Personalized Care Guidance

Integrate care planning with evidence-based guidelines, and provide clinical and non-clinical assessments. Create and apply care plans
with goals, provide follow-up with care coaches, and monitor adherence to the plan. Integrate data from intelligent devices.

Solutions
Beginning
• Health Cloud Care Plans
• Create and Use Care Plans
• Care Plans Help Simplify Onboarding

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• Manage Patient or Member Care to Improve Outcomes

• Engage the Patient’s Supporters to Customize and Coordinate Care
• Provide Assessments for Gathering Information
Intermediate
• Use Care Plan Adherence Dashboards
• Care Performance Analytics Dashboards and Story
Advanced
• Use Mulesoft to Integrate with Salesforce

Capabilities

CAPABILITY BEST PRACTICES

Experience Design • Conduct user-focused design research.

The process of shaping brand interactions based on an • Define user goals in customer-centric language.
understanding of user behavior and expectations. Apply
– Use empathy to better understand users.
experience design principles to every marketing interaction,
message, and touchpoint. – Use human language, not system or tech-centric language.

• Consider the user’s context. For example, what location is the

customer in? Are they on the go, at their desk, using a kiosk,
or using a mobile device.
• Gather feedback in a non-intrusive manner.
• Document and share findings from user-focused design
research with all business users, partners, and stakeholders.
• Formulate, socialize, distribute, and conduct enablement on
experience design principles and guidelines specific to your
brand.
• Ensure that marketing campaigns, journeys, messages, and
interactions reflect experience design principles.
• Build in feedback loops that enable users, employees, and
partners to comment on experiences.
• Revisit user-focused design. Research and update experience
design principles and guidelines.

Single View of the Customer • Identify the most critical data sources based on customer
Align relevant data sources at the individual customer level to lifecycle stages and moments that matter, prioritizing the top
support customer-centric marketing efforts. 3–5 customer journeys. Use the top journeys to inform business
requirements for data alignment or integration work.
• Create a data model with primary and secondary customer ID
fields and keys.
• Deploy an identity solution to connect users across devices
using deterministic and probabilistic approaches.
• Add secondary priority data sources.

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CAPABILITY BEST PRACTICES

Lifecycle Marketing • Define the lifecycle by industry or organization. A basic lifecycle

Tailor marketing messages based on each stage of the consists of awareness, acquisition, onboarding, engagement,
customer’s lifecycle. and retention.
• Define customer needs and moments that matter to customers
at each stage of the lifecycle.
• Develop a well-defined customer lifecycle, and use it to
orchestrate messages across touchpoints.
• Use analytics to place contacts, leads, prospects, or customers
in a lifecycle stage.
• Develop a set of tactics for each stage of the lifecycle that
addresses customer needs and company goals. For example,
assign lapsed customers a win-back campaign when they
haven’t opened or clicked an email in the past 6 months.
• To orchestrate the correct messages and channels in each
lifecycle stage, build automations and audience segmentation
activities.
• Implement a dynamic system that can move customers
through the current lifecycle stages and into new stages.
• Coordinate channels. Use personalization to engage customers
at each stage of the lifecycle.
• To create experiences that are lifecycle-driven, build customer
capabilities.

Modern Architecture Approach • Aggregate structured and unstructured data about each
All business lines involved in the customer journey have a full customer from across the organization for a unified customer
enterprise view of each customer, including profile, preferences, view.
products, and services. • Use the unified customer view that includes segment data to
build personalized interactions for every customer regardless
of where the interaction happens.

Chat Channel • Identify priority chat channels, and locations and products to
Provide an engaging and personalized shopping experience deploy chat.
by connecting customers with the right person for guidance • Organize your content to align with the right channels.
and advice.
• Establish operations and strategic key performance indicators.
• Enable chat.
• Set up request routing.
• Specify a location for chat.
• Determine what records to link to chat.
• Create an offline form option.
• Deploy chat to relevant pages.

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CAPABILITY BEST PRACTICES

Campaign Planning • Align on company business goals and key performance

Work across departments to define and align on campaign indicators.
and promotion strategy. • Ensure a consistent experience by defining campaign planning
across all channels.

Behavioral Email Strategy • Understand customer on-site behavior to identify opportunities

Define and manage behavioral emails, including segmenting, for behavioral emails, for example, when a customer abandons
targeting, AI, and content. a search, cart, or product description page.
• Create email journeys for a defined strategy.
• Define benchmarks and key performance indicators to measure
success.
• Deploy and regularly test to validate benchmarks and key
performance indicators.

Journey Design • Identify marketing objectives, campaigns to support each

Use a consistent approach to the design and development of objective, audience targeting requirements, data variables, and
customer journeys across all channels and stages of the attributes needed. Map where and how to source this
customer lifecycle. information. Use a journey design roadmap.
• To identify customer lifecycle and moments that matter, hold
a cross-functional workshop. Workshop journeys for four types
of moments that matter. For each journey, define a goal,
audience, data needs, content, and channels.
• Identify the content based on two types. In-journey content
is the delivered message that can be consumed without leaving
the inbox or screen. Outside-journey content includes the
resources that the customer navigates to with a click or tap,
such as web content.
• Prioritize journeys based on evaluation criteria, and create a
journey backlog.
• Design a simple, single-channel journey to start. For example,
a welcome email triggered by registration or conversion event.
• Evolve journeys to multiple channels, connecting multiple
journeys.
• Incorporate experience design principles in journeys.

Knowledge Management Approach • Align on the article lifecycle stages and actions associated with
Capture and distribute reusable, relevant, and accurate each stage. Common stages are draft, review, approve, publish,
knowledge content across one or more channels internally and archive.
and externally to customers and partners. • Identify owners for each stage of the lifecycle and approval
process by article type or data category.
• Identify subject matter experts who can write articles about
your products and services.

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CAPABILITY BEST PRACTICES

• Enable Email-to-Case so that agents can send articles to

customers.
• To help track individual, group, and organizational article
quality trends and effectiveness over time, install the Article
Quality Index managed package from AppExchange
• Install the Knowledge Article Feedback managed package from
AppExchange.
• To help find and classify articles, questions, or ideas, define
data categories.
• Enable feed tracking on knowledge articles and tagging on
knowledge articles.
• Add an actions and recommendations Lightning Web
Component to the case page layout or console layout.
• Ensure that case titles are accurate, clear, and follow the
structure defined by the business or IT.
• Decide which languages you want to translate in-house versus
sending articles to a localization vendor. If there are at least
three languages, ensure that there’s a version management
process in place for all translated articles.
• Ensure that communications go out to team members involved
in the knowledge lifecycle process.
• To help find and classify articles, questions, or ideas, define
data categories.
• Define article record types.
• Enable feed tracking on knowledge articles.
• Enable tagging on knowledge articles.
• Ensure that articles are rated so that agents can get an
understanding of how effective the article is.

Account Segmentation Approach • Align segmentation to the organization’s wider business goals.
Define, prioritize, and combine segment attributes. Group • Ask sales, marketing, service, the business unit, and other key
accounts to support business goals. leaders to define the overarching business goals.
• Let sales leaders derive objectives that support business goals.
• Ask sales leaders and sales operations to identify key attributes
that help profile accounts. Use qualitative and quantitative
data such as industry, number of employees, and future
revenue potential.
• Combine multiple attributes for a well-rounded segmentation
approach.

Customer Segmentation for Service • Segment customers by demographics, behavior, geography,

Align corporate customer segmentation models to determine benefit, or customer journey or other relevant qualities.
service support and channel strategies.

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CAPABILITY BEST PRACTICES

• Create customer profiles that provide useful information and

context for each customer.
• Tailor customer support experiences based on customer
segment. For example, target specific customer segments for
more or less personalized service based on spend or value.
• Address concerns before they arise, and make every customer
service interaction special.

Solutions for Personalizing Care

These solutions support capabilities within the Personalize Care in Healthcare Payer Organizations business scenario in the Customer
360 Guide for Healthcare Payers. For details about capabilities tied to these solutions, review each business scenario separately.

Access a Holistic Member View

Learn more and review capabilities for this area.
Beginning
• Customize Patient Card Data
• Customize Patient Data Displays
• Get to Know the Health Cloud Console
• Display a Patient’s Life Events
• Set Up Social Determinants to Assist High-Risk Patients and Members
• Customize a Timeline View
Intermediate
• Omni-Channel Supervisor
• Monitor Your Contact Center with Omni-Channel Supervisor
• Healthcare Integration with Mulesoft
• Interoperability and the Clinical Data Model
Advanced
• MuleSoft Accelerator for Healthcare
• Salesforce Integration: Guide to Healthcare Interoperability (white paper)
• Power the next generation of healthcare innovation (thought leadership)

Handle Member Inquiries

Learn more and review capabilities for this area.
Beginning
• Service Cloud Routing
• Einstein Next Best Action
• Einstein Next Best Actions Considerations

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Customer 360 Guide for Healthcare Payers Personalize Care in Healthcare Payer Organizations

Intermediate
• Omni-Channel for Lightning Experience
• Understand Skills-Based Routing
• Get Started with Einstein Next Best Action

Collaborate with Members on a Self-Service Portal

Learn more and review capabilities for this area.
Beginning
• Experience Cloud Setup Checklist
Intermediate
• Manage Your Site’s Pages and Their Properties in Experience Builder
• Build an Experience Cloud Site with Knowledge and Chat

Engage Members Throughout the Care Journey

Learn more and review capabilities for this area.
Beginning
• Email Marketing Best Practices
• Engage the Patient’s Supporters to Customize and Coordinate Care
• Email Design Toolkit
• Manage Campaigns with Health Cloud
Intermediate
• Getting Started: Marketing Cloud: Data and Segmentation Basics
• Getting Started with Email Studio
• Manage Customer Journeys
Advanced
• Advanced Customer Journeys
Thought Leadership
• Enhance Patient and Member Engagement Guide

Establish Care Programs for Members

Learn more and review capabilities for this area.
Beginning
• Health Cloud Care Plans
• Set Up Care Plans
• Create and Use Care Plans
• Care Plan Templates Help Simplify Onboarding
• Provide Assessments for Gathering Information
• Service Cloud Agent Experience

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• Manage and Work with Cases

Intermediate
• Set Up Case Escalation and Entitlements

Find Specialists to Manage Member Health

Learn more and review capabilities for this area.
Beginning
• Health Cloud Provider Relationships and Search
• Help Patients to Connect with Providers
Intermediate
• Set Up Data for Provider Search (help article)
• Set Up Data for Provider Search (developer guide)

Manage Member Health with Rewards and Recommendations

Learn more and review capabilities for this area.
Beginning
• Enable Care Teams to Track Gaps
• Einstein Next Best Action
• Get Started with Einstein Next Best Action
Intermediate
• Get Started with Loyalty Management

Manage Member Medication and Care Requests

Learn more and review capabilities for this area.
Beginning
• Medication Management
• Configure Patient Medication Manager
• Understand the Utilization Management Data Model
• Handle Care Requests with Utilization Management
Advanced
• Connect to a Benefit Verification Service

Manage Population Health

Learn more and review capabilities for this area.
Beginning
• Email Marketing Best Practices
• Engage the Patient’s Supporters to Customize and Coordinate Care
• Discover the Social Determinants of Health Data Model

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Intermediate
• Manage Patient Risk with Analytics for Health Cloud: Risk Stratification
• Set Up Einstein Analytics for Health Cloud Risk Stratification
• Use Patient Segmentation and Social Determinants Dashboards
• Audience Segmentation
• Manage Customer Journeys
Advanced
• Advanced Customer Journeys
• Get Insights from Your Health Cloud Data with CRM Analytics for Health Cloud
• Set Up the CRM Analytics for Healthcare App
Thought Leadership
• Enhance Patient and Member Engagement Guide
• How Healthcare CRM is Transforming Population Health
• Technology Enabled Population Health (video)

Monitor Member Experience

Learn more and review capabilities for this area.
Beginning
• Design and Distribute Surveys with Salesforce Feedback Management

Provide Personalized Care Guidance

Learn more and review capabilities for this area.
Beginning
• Health Cloud Care Plans
• Create and Use Care Plans
• Care Plans Help Simplify Onboarding
• Manage Patient or Member Care to Improve Outcomes
• Engage the Patient’s Supporters to Customize and Coordinate Care
• Provide Assessments for Gathering Information
Intermediate
• Use Care Plan Adherence Dashboards
• Care Performance Analytics Dashboards and Story
Advanced
• Use Mulesoft to Integrate with Salesforce

Solution Architecture for Healthcare Payers

Identify the specific tools and resources that can help you deliver comprehensive automation solutions for healthcare payer organizations.

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Customer 360 Guide for Healthcare Payers Solution Architecture for Healthcare Payers

Solution architecture diagrams show you how recommended products interoperate with backend systems and how data is passed
between them. Learn with Trailhead.

Healthcare Payer Solution Architecture with Key Clouds

The Salesforce healthcare payer architecture runs on three highly scalable and interoperable platforms: the core Salesforce Platform,
Marketing Cloud, and Commerce Cloud.
Products built on the Salesforce Platform (1) include Health Cloud, Order Management System (OMS), Experience Cloud, Loyalty &
Rebates Center, Asset Management and Field Service, CRM Analytics, Identity, and Privacy Center. These products all operate on the
same logical platform and share a flexible, common, and interoperable healthcare data model.
• Health Cloud (2) is a superset of Sales Cloud and Service Cloud features customized for healthcare organizations. Health Cloud
integrates sales, service, and marketing capabilities to provide a consistent experience across financial services departments and
channels.
• Order Management System (OMS) is a Commerce Cloud product, but it runs natively on the core Salesforce Platform. APIs enable
integration with other Salesforce and non-Salesforce platforms.
• CRM Analytics has direct connections to the Salesforce Platform and is best suited for Sales and Service analytics.
• Customer 360 Identity features single sign-on (SSO) and authentication management to ensure that employees, customers, and
partners sign on safely across all your applications and systems.
• Customer 360 Privacy Center manages data retention and rights, and it actively manages consent to ensure compliance with global
and local privacy and consent rules.
• The Salesforce Platform can be used in several ways.
– As an engagement layer
– As a customer master

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– As an editable or non-editable certified copy of customer master data

– To integrate with a third-party Master Data Management system

Salesforce Marketing Cloud (3) is a powerful suite of communication and marketing automation tools designed for interoperability.
• Datorama offers deep marketing analytics.
• Interaction Studio provides real-time interaction management, personalization, and AI-drive recommendations.
• Social Studio enables social monitoring and social media interaction management.
• Journey Builder stitches these tools together. It provides campaign management and delivers cross-channel, personalized experiences
at every step of the customer lifecycle.
Data Cloud (4) is Salesforce’s enterprise-wide CDP solution. Data Cloud delivers a unified profile by bringing together customer source
records, transactions, engagement activities, demographics, and signals from first or third-party data sources. It provides marketers a
single source of truth for their customer and makes that data available for creating personalized experiences across every touchpoint.
Commerce Platform (5) is a highly scalable platform for web and mobile ecommerce.
AppExchange (6) is the leading enterprise cloud marketplace with over 4,000 solutions to help extend Salesforce into any department
or industry. Over 1,000 consultants have deep expertise to drive business transformation.
Tableau (7) is a business intelligence platform and has direct connections to the rest of Salesforce. Tableau provides analytics independent
of data sources.
Mulesoft Anypoint Platform (8) is an integration platform designed for service-oriented architecture (SOA), Software as a Service (SaaS),
and APIs. Mule ESB, CloudHub iPaaS, API Manager, and hundreds of SaaS and on-premises connectors and templates are the building
blocks of this unique connectivity platform for integration.
• Use APIs to connect applications, data, and devices, both on-premises and in the cloud.
• Rearchitect a service-oriented architecture from legacy systems, proprietary platforms, and customer integration code.
• Migrate technology infrastructure to the public or private cloud, and prioritize adoption of SaaS applications and other cloud
technologies.
• Deploy integrations in a hybrid environment, connecting to SaaS applications and on-premises systems.

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Healthcare Payer Solution Architecture with Connectors

Developing point-to-point connections with API solutions allows customer experiences to cross Marketing, Service, and Commerce
platform boundaries.
API Integration (1) allows the Commerce platform to initiate actions in the Marketing platform.
• Track page views, searches, product views, cart contents, and order placement.
• Manage marketing opt-ins, email subscriptions, and preferences.
• Trigger transactional email, including account creation and update messages, password recovery, customer service messages, and
order confirmation.
• Trigger behavioral emails, such as messages about abandoned carts, and browse and wishlist-related messaging using a combination
of productized solutions and API integrations.
• Sync data such as product catalogs, customer information, order details, and promotional details.
• This connector is community code and provides a development framework for customers to follow.
API Integration (2) integrates Commerce Cloud to Health Cloud. The integration allows for data synching between the two clouds to
support several use cases.
• Submit cases from anonymous or registered customers.
• Retrieve case details for a registered member from Health Cloud.
• Sync profiles of registered customers and profile-specific addresses between Commerce and Health Clouds.
• A community-based solution exists to provide an enablement framework for developing this integration. For more information,
contact your account team.
Pre-built Salesforce connectors enable the connectivity that allows the cross-cloud actions required to support sophisticated use cases.
These types of use cases include delivering a follow-up email based on customer inquiry about their financial goals.

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Marketing Cloud Connect (3) connects Marketing platform products with Health Cloud products. The connector allows data to sync
between clouds. It also allows Marketing Cloud products to trigger events such as emails and journeys based on Health Cloud data.
• Automatically sync data from Health Cloud to Marketing Cloud.
• Connect Journey Builder to other clouds.
• Use Health Cloud data to construct email.
• Provide Marketing Cloud email tracking data such to Health Cloud products.
Distributed Marketing (4) allows users in Health Cloud to view, personalize, and send on-brand, best practice content through Marketing
Cloud.
• Use data stored in contact, lead, or person account records to address emails.
• Craft email to a segment of customers based on a list view.
• Send email about a campaign to a group of customers based on a touchpoint cadence managed by Marketing Cloud.
Social Customer Service (5) integrates Salesforce Platform functionality with Social Studio so agents and sales reps can respond to cases
and leads created from Facebook, Twitter, Instagram, YouTube, and other social networks.

SEE ALSO:
Salesforce Architectural Diagrams: Quick Look

Explore Solution Kits for Healthcare Payer Organizations

Enhance your cross-cloud business by implementing one or more solution kits. Get product recommendations, workflow details, and
instructions to help you implement the solution from start to finish.

Related Content

• Explore Salesforce Solution Kits

• Salesforce Solution Kits: Quick Look Trailhead Module

Solution Kit View in Salesforce Download Kit as a

Docs PDF
Create a Custom Preference Center View Now
Integrate the Salesforce core Individual object with Marketing Cloud’s Profile
Center and Subscription Center.

Personalize Marketing Recommendations View Now Download PDF

Keep shoppers interested in your products using email recommendations based
on merchandise that your customers already purchased from you.

Manage Vaccine Communications with Marketing Cloud View Now

Use Marketing Cloud to deliver timely communications about registering for
the vaccine and scheduling follow-up appointments.

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Customer 360 Guide for Healthcare Payers Explore Solution Kits for Healthcare Payer Organizations

Solution Kit View in Salesforce Download Kit as a

Docs PDF
Run Conversational Campaigns for SMS View Now Download PDF
Link customers directly from marketing messages to a live SMS chat with your
agent or chatbot for any questions about the product promotion.

Run Conversational Campaigns for WhatsApp View Now Download PDF

Link customers directly from marketing messages to a live WhatsApp chat with
your agent or chatbot for any questions about the product promotion.

Schedule an Appointment View Now Download PDF

Implement scalable processes to let shoppers schedule appointments to meet
locally managed or customer-preferred social distancing preferences.

SEE ALSO:
Salesforce Solution Kits: Quick Look

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