Production AI agent programs for enterprise leaders

Problem. Patient access capacity is consumed by routine booking traffic, capping the volume a health system can serve without adding headcount.

Agent design. Voice agent on Amazon Connect and Lex authenticates the patient, reasons over provider availability and scheduling rules, and writes the booking directly into the EHR — escalating to a human the moment a clinical question appears.

Outcome. Scheduling work completes end to end in the call, with clinical and exception traffic routed to patient-access staff with full context.

Acts in. EHR scheduling · Patient identity · CCaaS

Problem. Repetitive claims-status demand consumes member-services capacity that regulated appeals and grievance work needs.

Agent design. Agent authenticates the member, retrieves claim and EOB detail from the claims platform, explains denial reasons grounded in plan documents, and hands appeals to a specialist with the case assembled.

Outcome. Members resolve status, benefit and denial questions in channel; specialists work only the cases that need judgement. Appeals, grievances and eligibility disputes escalate to a licensed specialist with the case assembled.

Acts in. Claims platform · Member portal · Plan documents

Problem. A complex product mix drives inconsistent guidance and long handle times, and new advisers take months to reach proficiency.

Agent design. Assist agent reasons over product, policy and compliance content in real time, proposes next best action, checks the adviser's wording against disclosure rules and writes the wrap summary into CRM.

Outcome. Every adviser answers like the best adviser, with a compliance-checked record of what was said. The adviser reviews and sends every recommendation; nothing reaches the customer unapproved.

Acts in. CRM · Product and policy knowledge · Compliance rules

Problem. First-notice-of-loss intake is long and expensive, and incomplete data pushes rework and cycle time into the adjuster's queue.

Agent design. Agent conducts structured loss intake across voice and digital, collects photos and documents, validates coverage against policy admin, sets severity and books the adjuster.

Outcome. Adjusters open complete, coded claims instead of chasing the customer for missing facts. Coverage disputes, injury and suspected-fraud indicators escalate to an adjuster immediately.

Acts in. Claims system · Policy admin · Document capture

Problem. Order-status and returns demand triples at peak, forcing seasonal hiring that never pays back.

Agent design. Agentforce service agents call OMS and commerce APIs to track, cancel, reship and refund within policy limits, with voice fallback on Amazon Connect and a single context handoff to a human.

Outcome. Order and returns work is completed by the agent across web, app and voice — not deflected to a form.

Acts in. OMS · Commerce platform · Payments

Problem. Sampling 1–3% of interactions leaves client risk unmeasured and makes quality claims impossible to defend in a QBR.

Agent design. Scoring agent evaluates every voice and digital interaction against client-specific scorecards, with calibration sets, confidence thresholds and a dispute workflow the client can audit.

Outcome. Defensible per-client quality reporting on full volume, and the scoring foundation quality-aware routing builds on. Low-confidence scores route to a human reviewer, and clients can dispute any score.

Acts in. Interaction recording · QA scorecards · Coaching workflow

Problem. Billing and coverage conversations require staff to reconcile four to six systems live, which slows resolution and creates compliance exposure.

Agent design. Assist agent retrieves balance, coverage eligibility and script-safe payment-plan options in real time and proposes the compliant next step for the representative to confirm.

Outcome. Consistent, compliance-safe financial conversations resolved on the first contact. The representative approves every financial commitment before it is offered.

Acts in. Billing / RCM · Eligibility · Payment plans

Problem. Star and CAHPS performance carries direct revenue consequence, yet the drivers sit unread inside unstructured member conversations.

Agent design. Analysis agent classifies every interaction against Stars and CAHPS driver models, links themes to measure impact and pushes coaching moments into quality workflows.

Outcome. Member-experience investment is targeted at measures that move revenue, with evidence per driver. Quality leaders review and approve driver findings before coaching plans change.

Acts in. Interaction analytics · Quality management · Member survey data

Problem. Early-stage collections is high-volume, low-margin work where regulatory error is more expensive than the balance recovered.

Agent design. Voice agent works policy-grounded scripts within FDCPA and UDAAP guardrails, takes payments and arrangements inside limits, and hot-transfers on any hardship or dispute signal — every turn logged.

Outcome. More balances resolved per dollar spent, with a complete audit trail for compliance review.

Acts in. Collections platform · Payments · Consent and compliance log

Problem. Self-pay and balance-after-insurance accounts are expensive to reach and carry patient-billing compliance risk on every contact.

Agent design. Voice and SMS agent authenticates the patient, presents policy-approved payment-plan options, takes payment within limits and transfers on any hardship or dispute signal.

Outcome. More balances resolved per outreach dollar, with a complete compliance record.

Acts in. Billing / RCM · Payments · Consent log

Problem. Scheduling, billing, portal help and referrals sit behind separate numbers, so patients repeat themselves and calls multiply.

Agent design. One agent authenticates once, reasons across EHR, RCM and knowledge sources, completes the request in whichever domain it belongs to and hands off with full context.

Outcome. Single-contact resolution across patient services and fewer repeat calls. Clinical questions and financial hardship cases escalate to staff with the record attached.

Acts in. EHR · Billing / RCM · Referral management

Problem. Customers expect to move money and raise disputes digitally, and every routine transaction that reaches a call costs multiples of the digital path.

Agent design. Kore.ai agent authenticates the customer, executes balance, transfer and dispute-initiation transactions through core banking APIs within limits, and routes fraud and complex risk to specialists with context.

Outcome. Everyday banking completes in digital channels while risk cases reach the right team. Fraud, dispute and hardship intents escalate to a human banker with the session context.

Acts in. Core banking · Card and dispute systems · Identity