AI teammates for the work between the member and the claim.
Routina runs member outreach, care plan tracking, prior authorization intake, eligibility, and claims coordination for health plans and benefits brokers — on top of the core admin, care management, and EHR systems you already run. HIPAA-native, BAA-ready, bilingual EN/ES.
PAINS → SOLUTIONS
What slows a health plan down, and what Routina does about it.
Every member touchpoint crosses several systems and teams. Your nurses, pharmacists, and medical directors should spend their time on judgment — not on gathering, chasing, and reminding.
PAIN
High staff turnover
Member services and care coordination teams turn over constantly. Every departure takes process knowledge with it, and every new hire restarts training.
SOLUTION
Knowledge that stays when people leave
Outreach, intake, and follow-up workflows live in Routina, not in someone's head. Agents keep the routine work moving through every resignation, and new hires step into a process that's already running.
PAIN
Doing more with the same team
Membership and quality targets grow faster than care management headcount.
SOLUTION
Operate more efficiently
Agents run the routine outreach and case preparation. Across 4,000 members contacted for wellness visits, care managers only handle the 3% who need a human.
PAIN
Peaks, outages, and people out
Open enrollment, a hurricane, a call-out on a busy week — and member requests, prior auths, and outreach back up.
SOLUTION
Business continuity
Agents work around the clock and scale with the peak, with the full history of every member and case. Turnaround clocks keep running even when people can't.
PAIN
Getting care and supplies to members' homes
Home test kits, medications, supplies, and in-home assessments all depend on vendors the plan can't see into.
SOLUTION
Access to the Last-Mile Management Module
Routing, delivery windows, proof of delivery, and field-staff compliance on one platform — the same logistics operation Flexio runs for MMM and Triple-S.
PAIN
Prior auth requests that arrive incomplete
Requests come in by fax with half the clinical notes missing, and reviewers spend their time chasing paperwork.
SOLUTION
Reviewer-ready cases
Prior Auth Assistant extracts the request, verifies coverage, requests what's missing, and lays the case out against your criteria. Your clinicians make every decision.
PAIN
Members on three channels about one question
A member calls about a claim, texts about the same claim, then calls again — and gets three partial answers.
SOLUTION
One conversation per member
Every call, SMS, and WhatsApp message lands in one thread with the member's coverage and history, answered once, in English or Spanish.
PAIN
Care plans split across systems
The care plan lives in one system while the visits that close it live in another.
SOLUTION
Care plans that update themselves
Care Plan Assistant updates each member's plan as visits are scheduled and completed, and escalates the gaps to care managers.
PAIN
Members who never book the visit
Annual wellness and chronic care visits go unscheduled, and quality measures suffer.
SOLUTION
Outreach until it's booked
Member Outreach contacts each member, answers questions, books with their primary care group, and re-engages the ones who don't respond.
THREE OPERATIONS, ONE PLATFORM
Where Routina runs in health insurance.
Three operational shapes we see most. They share a platform but not a workflow. Each has its own agents, integrations, and rhythm.
Care Management & Member Services
Health plan care management programs and member services. Annual wellness scheduling, chronic care follow-up, care plan tracking, and member questions by SMS, WhatsApp, and voice. PMPM pricing.
Member Outreach contacts 4,000 plan members for annual wellness scheduling — answers questions via SMS and WhatsApp, books appointments, escalates the 3% who need human follow-up.
Utilization Management & Claims
Prior authorization intake, clinical document gathering, PBM coordination, and claims review support. Agents assemble the case; your clinical reviewers make every coverage decision.
Prior Auth Assistant turns an incomplete fax request into a complete case — member, coverage, clinical history, criteria — before a reviewer opens it.
Health & Group Benefits Brokers
Brokers placing group health, dental, vision, life, and disability for small-to-mid employers. Open enrollment, carrier rate shopping, employee communication, COBRA administration, and eligibility tracking.
Enrollment Coordinator runs open enrollment for a 240-employee group — schedules info sessions, sends bilingual enrollment links, tracks selections, drafts the final group census for the carrier.
ORIGIN
We've worked for health plans before we sold to them.
Routina started inside Flexio — a healthcare logistics operation in Puerto Rico delivering for MMM, Triple-S, and the largest specialty pharmacies on the island. Every agent was first run against real PHI, real auditors, and real member SLAs before it was offered to anyone else.
That's why the platform assumes what health plans actually deal with: members who prefer Spanish, requests that arrive by fax, and an auditor who wants to know exactly who touched a case and why.
IN PRACTICE
Two health plan workflows, start to finish.
What each step is, which agent owns it, what integration it touches, and what the operator sees.
COMPLIANCE
Payer-grade by default.
Not features we added. Conditions we built in.
HIPAA-Compliant Infrastructure
Encryption at rest and in transit. PHI logging, access controls, and audit trails — all on by default, not toggles you turn on later. BAA available for any tier.
Clinicians Make the Decisions
Agents gather, organize, and route. Coverage and medical-necessity determinations are made by your licensed reviewers — never by an agent.
Role-Based Access
Every agent action is scoped by user permission. Member services sees what they need, the clinical reviewer sees what they need, the auditor sees what they need.
Audit Trails by Default
Every agent action and member interaction is logged with who, what, when, and why. Audit-ready exports in seconds, not days.
INTEGRATIONS
The systems Routina already speaks.
Routina connects to the stack your plan or brokerage already runs. No migration, no rip-and-replace.
Core Admin Systems
Membership, eligibility, benefits, and claims status.
Care Management Platforms
Care plans, member tasks, and care manager queues.
FHIR-Compliant EHRs
Clinical history from provider systems.
PBM Claims
Prior authorization, formulary, claim status.
Provider Portals & Fax
Authorization requests and clinical documents on arrival.
Benefits & Carrier Portals
Group quotes, enrollment, and census submission for brokers.
Twilio
SMS and voice for member communication.
WhatsApp Business
Member and employee outreach in EN/ES.
e-Signature
Enrollment forms and broker proposals.
Don't see your system? We add new integrations in days, not quarters.
IN PRODUCTION
Health insurance operations running Routina, anonymized for HIPAA.
Health Plan Care Management
Coordinating annual wellness visits and chronic care management for plan members across multiple primary care groups. Routina runs member outreach, prior auth, and care plan tracking — PMPM pricing.
Health & Group Benefits Broker
Group benefits broker placing health, dental, and vision for small-to-mid employers. Routina pilot on open enrollment coordination and commission reconciliation.
GET STARTED
Ready to see what Routina does inside a health plan?
Book a 30-minute working session. We'll map your systems, identify the first two teammates to deploy, and answer the procurement and BAA questions before you have to ask them.