Key Takeaways
- Care management ROI shows up in three places: care manager capacity, documentation time, and utilization cost.
- Nascentia Health saved roughly six to seven full-time equivalents (FTEs) of labor by eliminating double data entry, and nurses took on 15% more cases without added staff.
- Suki ambient intelligence, embedded within Clinical Edge, formerly HealthEdge GuidingCare®, reduces time per note by 41% on average.
- A study of digital care management at a U.S. payer found $1,923 in savings per member over 90 days, with 17% fewer inpatient admissions and 9% fewer emergency room visits.
Why Is Care Management Return on Investment (ROI) So Hard to Measure?
Care managers work with members who are complex and hard to reach. Psychosocial factors and social determinants of health are almost always in play. Building trust with these members takes the right data and tools that bridge communication gaps.
The systems behind that work rarely help. Care settings and community services sit in separate systems that don’t share data. Care managers log into several tools to assemble one member’s picture. Caseloads keep rising while time with members shrinks. When the work is fragmented, the evidence of its value is fragmented too.
How Does Clinical Edge Support Health Plan Modernization?
Clinical Edge consolidates care management, utilization management, appeals and grievances, provider authorization, population health, analytics, and member engagement within a single integrated solution. This consolidation makes it easier for health plans to utilize member data, connect care teams, and streamline workflows to deliver whole-person care across all lines of business.
With an integrated care management solution like Clinical Edge, ROI can surface in key areas like:
1. Enhancing Care Manager Capacity & Efficiency
Nascentia Health, a long-term services and supports (LTSS) organization in New York, ran on disconnected tools, manual workarounds, and vendor-dependent updates. After moving to Clinical Edge, it reported:
- Six to seven FTEs worth of labor saved by eliminating double data entry
- 15% more nurse case capacity without added staff
- 90% of configuration changes handled internally
- Support response times under 30 minutes
Clinical Edge rollout took just nine months compared to the typical 12 to 15 months for other enterprise care management solutions.
“This was one of the most collaborative, efficient implementations I’ve ever seen.”
-VP, Health Plan Operations and Administration at Nascentia Health
2. Streamlining Documentation & Clinical Decision-Making
Embedded AI tools within Clinical Edge help care managers spend less time on documentation and more time proactively identifying at-risk members, delivering early interventions, and reducing unnecessary hospitalizations.
With ambient clinical intelligence, conversations between care managers and members become structured clinical notes within their existing workflows. This integration cuts time per note by 41% on average, meaning care teams can redirect their time from documentation to direct outreach, assessments, and earlier intervention. It also reduces after-hours work by 37%—a drastic impact when nearly half of clinicians report burnout.
With Clinical Edge, one health plan regained a full star within one year after losing its 4 Star Rating. This rapid innovation demonstrates how the care management solution enables health plans to stabilize operations, improve clinical outcomes, and optimize revenue through enhanced provider engagement.
3. Supporting Cost Control & Quality
A study in the Journal of Medical Economics evaluated the Member Engagement module within Clinical Edge using propensity matching. The study reviewed data from members who used the solution over a 90-day period, and found that use of Member Engagement led to:
- $1,923 in savings per member
- 17% fewer inpatient admissions
- 9% fewer emergency room visits
- 29% higher use of preventive services
These are utilization measures with direct financial consequences. The care management solution also provides transparent cost tracking, making it easier for payers to accurately quantify cost reductions and expense management achievements.
How Can Health Plans Build a Business Case for a New Care Model?
Separate direct benefits from indirect ones. Direct benefits include fewer admissions and emergency room visits, lower administrative labor cost, and shorter implementation time. Indirect benefits include less documentation burden, stronger audit readiness, and higher-quality performance.
Because care management, utilization management, and member engagement run on one platform, attribution does not require reconciling data across systems. Clinical Edge supports 28M+ contracted lives across 50+ organizations, with 100K+ users. These results come from a mature platform, not a pilot.
To see how payers measure ROI across their most complex populations, download our eBook, Mastering Complex Care for Long-Term Services and Supports (LTSS).
Want to learn more about the Clinical Edge solution? Read our infographic, Top 9 Reasons More Payers Choose HealthEdge® Clinical Edge Than Any Other Care Management System.