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For payers. Decisions at member speed. Governance intact.

Faster decisions. Tighter governance. Members who do not wait seven days for a yes. Utilization management, claims operations, appeals, and FWA all running on the same Operating System with the same Glassbox audit trail.

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The wait was never the plan

Members were never supposed to wait seven days for a yes.

Prior auth volumes have doubled in a decade. Appeal volumes are climbing. Staff turnover is at all-time highs. Every day you ship fewer determinations than came in, the backlog compounds. Penguin Ai is the operating layer purpose-built to handle that volume responsibly.

Built for payer operations

Three solutions, one Operating System, one audit trail.

Intelligent Utilization Management

End-to-end UM. Prior auth automated for cases that meet criteria. Concurrent review with length-of-stay tracking and escalation. Retrospective review at scale. Clinical reviewers focused on the cases that need them, not on the queue depth.

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Intelligent Risk Adjustment

Prospective capture and retrospective recovery on one closed loop. MEAT evidence assembled with every code. CMS-HCC and HHS-HCC supported. RADV-ready provenance by default, not bolted on at audit time.

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Member 360

A complete member view assembled across every connected system — eligibility, clinical history, claims, prior auth chain, and care management. Reviewers, care managers, and operations teams start with full context, not a chart chase.

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Payer Solutions

Risk adjustment and Snowflake-native deployment, built for payer operations.

Snowflake Native Apps

Penguin Ai's Ai Workers, packaged as Snowflake Native Apps, running where your data already lives. No egress pipelines. Governance stays yours.

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Governance baked in

Audit prep stops being a quarterly scramble.

Every determination is logged with full Glassbox traceability. Every reviewer action is captured. Every policy version is preserved. CMS reporting comes out of the system, not out of a spreadsheet someone built three years ago.

Built by people who ran payer ops

The Operating System is informed by the spreadsheets we built and the manual processes we inherited.

Our founding team ran data operations at the largest payers in the country. If those workflows sound familiar to your team, Penguin Ai will feel familiar from the first demo.

Related on Penguin Ai

Where this connects.

Providers

Care over keyboard. Documentation handled. HCC capture defended. The other side of the boundary, on the same Operating System.

Home Health

Grow census. Hold margin. OASIS audit-ready. Field clinician documentation time returned to actual visits.

Solutions

End-to-end agentic workflows for utilization management, RCM, Patient 360, and HCC retrospective.

The Operating System

The Data Layer, the Context Layer, and the Ai Workforce — what every payer Solution stands on.

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See the Operating System run against your UM, appeals, and FWA workflows.

A Penguin Ai specialist will walk through how the Operating System handles volume responsibly while keeping your reviewers in command of clinical judgment.

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See payer use cases