Clinical Expertise Empowering smarter healthcare decisions with embedded clinical care navigation
Healthcare is complex. Delayed carefragmented systems and unnecessary costs make it harder for employees to get the care they need. Quantum Health’s clinical care model changes that by intervening earliercoordinating care smarter and driving better holistic health outcomes with an in-house clinical team.
Our unique model integrates care navigation, utilization management, wellbeing support and provider engagement to create a seamless healthcare experience. Starting with clinical expertise and provider collaborationwe ensure early interventionprevent fragmented care and ultimately enable members to make the best decisions for their care.
Our integrated clinical care model drives better outcomes
Unlike other navigation platformsQuantum Health:
- Engages members at the earliest signs of a healthcare eventoften before claims are filedthrough Real-Time Intercept®
- Provides dedicated clinical supportincluding in-house doctorsnursespharmacists and care teams that work together to guide members
- Reduces healthcare costs through optimized care pathsutilization management and provider collaboration to cut unnecessary expenses
- Improves health outcomes by enabling more preventive screeningsfewer hospital readmissions and increased provider engagement
Our Personal Care Guide (PCG) nurses are dedicated advocates
Quantum Health is the only independent navigation solution with an in-house clinical support team – doctorsnurses and care coordinators working together. Our PCG nurses are embedded in each client’s team and become a member’s advocate to help assessplan and evaluate the best options for their healthcare needs. They blend case management and chronic condition management with dedicatedempathetic support. PCG nurses guide members through care gapsreducing preventable hospital visits and ensuring adherence to treatment plans.
Our approach goes beyond traditional utilization management
We fully own the utilization management (UM) processadvocating for our members in real time through proactive and ongoing consultation with the member’s providerensuring faster approvalsfewer denials and optimal site-of-care decisions.
We prevent denials by working directly with providersresolving missing documentation before claims are submitted. Our nurses perform reviewsassess progress and help ensure the appropriate level and setting of care. All these factors help eliminate unnecessary inpatient days and address potential barriers to dischargeleading to cost-effective care and clinically better outcomes.
denial rate vs. the standard 9% carrier denial rate
Reduced inpatient stays
savings through utilization management and site-of-care review for specialty drugs on the medical benefit
It’s about ensuring they get the right care at the right time.
Our clinical model increases preventive screenings and care leading to healthier employees and lower healthcare costs.
Our doctorsnursespharmacists and other experts provide personalizedholistic guidance that ensures smarter care decisionsreduced costs and better outcomes. Discover how our clinically integrated approach helps employers manage specialty drugs.
See how a clinically focused approach transformed their healthcare and benefits strategy.
National Church Residences turned to Quantum Health to improve preventive care and chronic condition management—engaging members 120 days earlier and reducing high-cost claims.
Frequently Asked Questions
Unlike traditional navigation solutions that focus primarily on administrative support or digital engagementsQuantum Health’s Clinical First™ model integrates in-house physiciansnursesand pharmacists to guide members at every step of their healthcare journey. Through Real-Time Intercept® (RTI)we engage members and providers before high-cost claims occurensuring early intervention and evidence-based care decisions. This approach leads to:
- 16.8% increase in preventive care utilization
- 4.3% reduction in inpatient hospital stays
Over 50% of our clinical team’s interactions are directly with providersensuring smarter site-of-care decisionsfewer denied claimsand faster approvals. Our Personal Care Guide (PCG) nurses work closely with providers on pre-certificationstreatment planningand chronic condition managementleading to better adherence to care plans and fewer unnecessary hospitalizations. This hands-on approach lowers out-of-pocket costs for employees and drives long-term savings for employers.
Specialty drugs can be a major cost driver for employers. Quantum Health’s Pharmacy Services team evaluates site of carenegotiates lower-cost optionsand ensures clinically appropriate usage. By shifting specialty drug treatments to lower-cost sites when appropriatewe’ve helped client achieve:
- $2.08 PMPM savings through site-of-care reviews
- 43% lower costs when treatments move from outpatient hospital settings to home or office settings
- 91% success rate in recommending alternativecost-effective drug administration locations