Industry  |  Healthcare Payer

Better member outcomes.
Healthier margins.

AI-powered workflows are helping payers resolve member inquiries instantly, close care gaps on time, and automate operations to improve medical loss ratio.

The forces reshaping how payers compete

Medical loss ratio

Rising utilization and manual claims processes keep administrative costs high and margins under pressure, leaving little room to invest in the member outcomes that define long-term competitiveness.

72%

Medicare Advantage plans operated with negative EBITDA

McKinsey & Company

Prior authorization & claims

Automating prior authorization is now a regulatory mandate, but manual review cycles, fax-based workflows, and siloed clinical data continue to delay decisions and erode provider and member trust.

93%

physicians say prior auth delays necessary care

American Medical Association

Member experience

CMS has doubled the weight of member satisfaction in Star ratings, but fragmented channels, reactive outreach, and disjointed benefit navigation consistently fall short of member expectations.

$12.7B

Star Rating quality bonuses at stake in 2025

Kaiser Family Foundation

Employee productivity

Highly skilled employees lose productive hours to repetitive tasks, information gathering across fragmented systems, and manual workflows, leaving little capacity for the work that actually matters.

57%

of work hours are already automatable

McKinsey & Company

Your AI playbook

Start with the function where your highest-cost inefficiency lives. Most organizations build the ROI case there, then expand across functions.

Roadblocks to Every Turn

Rising customer expectations, frequent bad experiences, and overwhelmed agents create constant service bottlenecks.

A Smarter way to Help

Autonomous AI-powered agents provide AI-driven support for human agents and enable continuous service improvement.

Empowered Results for All

Delivering frictionless customer experiences, empowering agents to perform at their best, and driving elevated business outcomes.

Use tabs to explore more

Member experience

AI agents resolve two-thirds of member interactions without a live agent, while surfacing real-time intelligence for calls that need a human.

40-60%

self-service containment

40-50%

faster response time

Star ratings

improvement

Benefits verification

Give members instant answers on deductibles, copays, and out-of-pocket maximums across voice and chat, deflecting routine benefit queries away from human agents.

learn more
Claim status & billing

Retrieve real-time claims processing and billing updates through AI agents, reducing inbound inquiries and improving member transparency.

learn more
Provider network search

Search for in-network doctors, specialists, and urgent care clinics by location, specialty, or accepted plan through AI agents in real-time, across all channels.

learn more
Eligibility tracker

Confirm eligibility, coverage status, and covered dependents in real time through AI agents, reducing inbound inquiries and call center load.

learn more
Prior authorization lookup

Confirm whether a specific medical service requires pre-authorization under the member's health plan through AI agents, and guide members to next steps.

learn more

Operations

Prior auth, denial management, and benefits administration drive medical loss ratio. AI agents auto-adjudicate qualifying requests and route exceptions to reviewers.

60-70%

faster prior auth decisions

75-85%

claims auto-adjudicated

15-30%

claim re-work reduction

Prior authorization automation

Streamline prior authorization workflows with AI-driven validation and auto-approval of low-risk submissions, reducing turnaround time and administrative burden.

learn more
Benefits and eligibility check

Give real-time member coverage details to providers in a single verified session to eliminate manual lookups and speed up point-of-care decisions.

learn more
Claim status tracking

Enable providers to check real-time member claim status, with instant updates on progress, approvals or denials, and pending actions.

learn more
Pend claim automation

Resolve pended claims faster with specialist AI agents that determine routine cases automatically, so SMEs focus only on decisions that need them.

learn more
Provider management

Keep provider directories current and compliant with AI agents, that validates and propagates updates in real time.

learn more

HR

HR service agents handle onboarding, offboarding, leave, and escalations across HRIS platforms, removing the administrative backlog.

60-80%

faster resolution

25-40%

savings in operational cost

10-15 point

higher employee satisfaction

Search/HR Help desk

Instantly deliver precise HR policy answers with AI, no portal navigation, just fast, accurate, country-specific guidance.

learn more
Absence management

Empower employees and managers with 24/7, policy-driven leave self-service, enabling confident time-off planning and seamless approvals.

learn more
Employee benefits management

Allow employees to explore, compare, and enroll in tailored benefits through a unified, secure HR application, driving engagement and satisfaction.

learn more
Employee onboarding

Streamline onboarding with automated, role-based workflows that accelerate productivity, ensure compliance, and deliver a seamless new-hire experience.

learn more
Employee offboarding

Simplify employee exits with automated workflows, coordinated task management, and actionable feedback, reducing risk and manual effort.

learn more
Manager self-service

Empower managers to update team details, process terminations, and submit recognitions in one guided, compliant workflow.

learn more

IT

IT service agents automate ticket triage, access governance, and incident coordination with HIPAA audit readiness across EHR and enterprise systems.

50–70%

faster resolution

30-50%

self-service containment

100%

audit trial for compliance

IT knowledge management

Unify IT knowledge from repositories, FAQs, and internal documents, empowering teams and streamlining support with instant, context-aware search.

learn more
Access management

Empower employees with rapid, secure access recovery, reducing IT intervention and ensuring business continuity through automated identity verification.

learn more
Request management

Accelerate IT request fulfillment with guided workflows, automated validation, and seamless approvals, all from a single, unified interface.

learn more
Incident management

Streamline incident reporting and resolution with automated diagnostics, knowledge suggestions, and real-time tracking for IT teams.

learn more
Endpoint remediation

Proactively resolve endpoint disruptions with intelligent automation, minimizing IT workload and maximizing employee uptime.

learn more
Ticket assignment

Effortlessly match every IT ticket to the right expert using AI-driven routing, ensuring rapid, accurate resolutions and balanced team workloads.

learn more

Recruiting

AI agents handle scheduling, transcription, and feedback collection automatically so recruiting teams focus on candidate quality.

20-30%

faster time-to-fill

60–75%

recruiter time saved

30–45%

lower admin overhead

Job description management

Streamline job description creation with AI agents that ensure compliance, consistency, and faster hiring for every open role.

learn more
Interview scheduling

Instantly coordinate interviews by matching candidate and interviewer calendars, automating confirmations, and rescheduling for a seamless recruiting experience.

learn more
Position creation

Eliminate hiring delays by launching ready-to-approve requisitions as soon as a resignation is recorded.

learn more
Candidate screening

Streamline candidate interviews with automated scheduling and voice-driven screening, delivering actionable insights directly to hiring teams.

learn more
Interview transcription and feedback

Transform interviews into actionable insights and ready-to-review feedback, reducing delays in candidate assessment.

learn more
Candidate experience

Deliver a seamless, AI-powered candidate journey and capture feedback for continuous improvement.

learn more

Finance

AI agents flag payroll exceptions, validate invoices, and maintain audit trails without manual review of every transaction.

50–60%

faster processing

95–99%

compliance accuracy

35–45%

faster response time

Payroll and expense compliance

Flags payroll anomalies and out-of-policy expense submissions before they process. Keeps a distributed workforce compliant without manual review of every run.

learn more
Invoice processing

Extracts invoice data, matches against POs and contracts, routes exceptions, and posts to ERP. AP teams handle only mismatches, not the full volume.

learn more

Delivering measurable outcomes

More margin

Contain high-volume member inquiries through self-service and reduce administrative cost without adding headcount.

Faster decisions, fewer appeals

Automate prior authorization and claims workflows to cut turnaround times and reduce costly manual rework.

Fully compliant

Reduce regulatory exposure with built-in HIPAA governance, CMS interoperability mandates and audit-ready documentation.

Improved member experience

Lift CAHPS and Star Ratings through proactive, personalized engagement across every channel.

Higher workforce productiutty

Free contact center and operational teams to focus on high-value work while AI handles the routine.

Three ways to get AI into production

Pre-built Application
Production-ready payer applications
  • Pre-trained healthcare AI agents
  • Proven payer workflows
  • Pre-built EMR, health plan integrations
  • HIPAA, SOC 2 Type II & GDPR compliant
Application Accelerator
Configure via the Kore.ai marketplace
  • 30+ payer use case templates
  • Visual workflow configuration
  • Pre-configured AI workflow
  • Plug-and-play components
Tailored Application
Build on the Kore.ai Agent Platform
  • Full lifecycle management of AI agents
  • Customizable multi-agent orchestration
  • Configurable guardrails and governance
  • No-code, Low-Code & Pro-code tools

AI for Healthcare - pre built integrations

Discover how payers are delivering value with Kore.ai

Background Image 4
Background Image 9
You are now leaving Kore.ai’s website.

Kore.ai does not endorse, has not verified, and is not responsible for, any content, views, products, services, or policies of any third-party websites, or for any verification or updates of such websites. Third-party websites may also include "forward-looking statements" which are inherently subject to risks and uncertainties, some of which cannot be predicted or quantified. Actual results could differ materially from those indicated in such forward-looking statements.



Click ‘Continue’ to acknowledge the above and leave Kore.ai’s website. If you don’t want to leave Kore.ai’s website, simply click ‘Back’.

×