Systems and methods for predictive personalization and intelligent routing

Abstract

Systems and methods for intelligently routing a member of an organization to a single point-of-contact within an optimized, secure network to address all the member's healthcare needs are described. The disclosed intelligent routing configurations transform and process, in real-time, vast amounts of member data to generate specialized effort scores specific to each member's household. The effort scores, among other things, are used to determine an appropriate tier within the organization to route the member, and its account file containing real-time member and household level data.

What is claimed is: 
     
         1 . A secure network for intelligently routing an individual to an organization representative, comprising:
 an authentication processor authenticating the individual using automatic number identification;   a natural language processor providing the individual with one or more open-ended questions and analyzing spoken content of the individual to determine an explicit need of the individual based on the spoken content being responsive to the one or more open-ended questions;   an input/output interface receiving the spoken content of the individual;   a conversation management processor:
 determining an implicit need of the individual, the implicit need of the individual being based on individual household data, a referral score and an effort risk score for the individual; 
 determining the referral score based in part on the household data, to correspond to a propensity of the individual to contact the organization regarding a program for which the individual's household is eligible; 
 determining the effort risk score to correspond to a likelihood of an individual in the individual's household being eligible for a program of the organization, all the individuals of the household receiving a same effort risk score; and 
 determining a tier of organization representative to route the individual based on the explicit need of the individual determined by the natural language processor and the implicit need of the individual determined via the individual household data. 
   
     
     
         2 . The secure network of  claim 1 , wherein determining the tier of the organization representatives comprises:
 routing the individual to a third tier representative when the individual household data satisfies at least one third tier routing rule, the at least one third tier routing rule comprising:
 a monetized value of the individual household data is greater than a first threshold value; and 
 a cost risk score of the individual household data is greater than a second threshold value; 
   routing the individual to a second tier representative when the individual household data satisfies at least one second tier routing rule, the at least one second tier routing rule comprising:
 an effort risk score of the individual household data is greater than a third threshold; and 
 the monetized value of the individual household data is between a fourth threshold and a fifth threshold; and 
   routing the individual to a first tier representative when the individual is not routed to the third tier representative or the second tier representative.   
     
     
         3 . The secure network of  claim 1 , wherein the authentication processor further requests the individual to provide additional individual information when the authentication processor does not authenticate the individual. 
     
     
         4 . The secure network of  claim 1 , wherein the input/output interface further receives historical individual activity data and the conversation management data storage further houses the historical individual data received by the input/output interface. 
     
     
         5 . The secure network of  claim 4 , wherein the input/output interface receives historical individual activity data on a periodic basis. 
     
     
         6 . The secure network of  claim 1 , wherein the natural language processor further determines an explicit need of the individual based on analysis of typed text of the individual. 
     
     
         7 . The secure network of  claim 1 , wherein the input/output interface further transmits tailored user interface data to a device of the representative the individual is routed to. 
     
     
         8 . The secure network of  claim 1 , further comprising a conversation management data storage housing data processed and/or generated by the conversation management processor wherein the conversation management data storage comprises a plurality of specially configured data stores. 
     
     
         9 . A system for intelligently routing an organization's member to an organization representative, comprising:
 a secure computing environment implementing specially configured security parameters, comprising:
 an authentication processor authenticating the member using automatic number identification; 
 a natural language processor providing the member with one or more open-ended questions and analyzing spoken content of the member to determine an explicit need of the member based on the spoken content being responsive to the one or more open-ended questions; 
 an input/output interface receiving the spoken content of the member; 
 a conversation management processor that:
 determines an implicit need of the member, the implicit need of the member being based on member household data, a referral score and an effort risk score for the member; 
 determines the referral score based in part on the household data, to correspond to a propensity of the member to contact the organization; 
 determines the effort risk score to correspond to a likelihood of an individual in the member's household being eligible for a program of the organization, all the individuals of the household receiving a same effort risk score; and 
 route the member to a tier of organization representatives based on the explicit need of the member determined via the natural language processor and the implicit need of the member determined via the member household data. 
 
   
     
     
         10 . The system of  claim 9 , wherein the authentication processor further requests a member to provide additional member information when the authentication processor does not authenticate the member. 
     
     
         11 . The system of  claim 9 , wherein the conversation management processor further creates an account file with routing files and effort risk files for the member. 
     
     
         12 . The system of  claim 11 , wherein the conversation management processor further updates the referral and effort risk scores for the member when the member's routing and effort risk files are loaded by the secure computing environment. 
     
     
         13 . The system of  claim 12 , wherein the conversation management processor generates a new member account file when the member is determined to be a new member. 
     
     
         14 . The system of  claim 9 , wherein the input/output interface further transmits tailored user interface data to a device of the representative the member is routed to. 
     
     
         15 . A secure network for intelligently routing an organization's member to an organization representative, comprising:
 an authentication processor authenticating an identity of the member;   a natural language processor determining an explicit need of the member based on analysis of responses from the member;   a conversation management processor configured to:
 determine an implicit need of the member, the implicit need of the member being based on member household data, the member household data including cumulative data for each of the individuals residing in a household of the member, determining the implicit need being further based on a referral score and an effort risk score for the member; 
 determine a tier of organization representatives to route the member based on the explicit need of the member determined by the natural language processor and the implicit need of the member determined via the member household data. 
   
     
     
         16 . The secure network of  claim 15 , wherein the member household data comprises:
 the referral score based in part on the household data, to correspond to a propensity of the member to contact the organization regarding a program for which the member's household is eligible;   the effort risk score to correspond to a likelihood of an individual in the member's household being eligible for a program of the organization, all the individuals of the household receiving a same effort risk score.   
     
     
         17 . The secure network of  claim 15 , wherein the authentication processor further requests a member to provide additional member information when the authentication processor does not authenticate the member. 
     
     
         18 . The secure network of  claim 15 , wherein the natural language processor determines an explicit need of the member based on analysis typed text of typed from the member. 
     
     
         19 . The secure network of  claim 15 , further comprising conversation management data storage housing data processed and/or generated by the conversation management processor. 
     
     
         20 . The system of  claim 15 , further comprising an input/output interface further transmits tailored user interface data to a device of the representative the member is routed to.