Using GenAI to Power Healthcare Navigation and Care Coordination

The presence and potential of generative artificial intelligence (GenAI) are advancing around the world, across virtually all industries, including healthcare. According to Maximize Market Research, global spending on AI-powered healthcare products and services is expected to grow by nearly 38% annually between 2024 and 2030.

As the leader in independent healthcare navigation and care coordination, Quantum Health is positioned to leverage generative AI at the intersection of health benefits and care utilization. Navigation Insider sat down with Quantum Health President Shannon Skaggs to learn how the company has been using GenAI within its operations to improve the healthcare and benefits experience.

Q: Overall, what role does GenAI play in Quantum Health’s healthcare navigation and care coordination platform?

A: GenAI plays a very integral role in driving innovation and value creation at Quantum Health. Healthcare and benefits are data intensive and highly complex. We invented independent navigation and care coordination to simplify that complexity for employers, benefits plan members and the providers who care for members. Because GenAI is all about distilling meaningful outputs from massive volumes of data, we’ve been using GenAI and its various subsets for years to do meaningful work on behalf of our stakeholders.

For example, machine learning helps us analyze a new client’s member population and identify opportunities to engage one-on-one with members who have chronic conditions. We use generative AI to summarize details of our member engagements, so our Care Coordinators can focus on supporting the member and spend less time taking notes. We also use natural language processing tools that detect health signals and give real-time prompts to our Care Coordinators. These systems help us act in real time on any emerging healthcare needs that surface during member conversations.

These are a few examples of how we’re using GenAI and there are many others. Our approach is both highly human-centered and tech-empowered. GenAI is one of the primary technologies empowering our Healthcare Warriors® to deliver the best possible navigation and care coordination.

Q: Describe the Warrior Assist™ tool, the company’s latest use of generative AI

A: Think of Warrior Assist as an always-on, incredibly smart and highly responsive copilot to our Care Coordinators. They can enter prompts that summarize even the most nuanced, multifaceted benefits questions a member or provider might pose. Warrior Assist will return an answer in split seconds, something that might take even our most experienced Warriors a few minutes or more to research.

The so-what for members and clients is that our Care Coordinators can spend more time focused on the healthcare needs behind members’ benefits inquiries. That might mean helping them make a cost-aware choice between ER, urgent care and telehealth services. Or, maybe it’s connecting them with a cancer-treatment or surgery center of excellence recently added to their benefits offering. And it can mean guiding them to community resources that will help overcome a healthcare access or equity barrier. 

Q: What’s the significance of Quantum Health’s Large Journey Model™ innovation?

A: GenAI tools like Warrior Assist need to be trained in order to produce useful outputs in response to users’ prompts. For example, GenAI tools can produce essays, articles and other content because they were trained on a large language model. Tools trained on a large image model will generate art and photos. Autonomous car companies use large driving models to develop their products.

In the navigation and advocacy space, Quantum Health ingests what we believe is the most robust data set. That’s because our model uniquely connects clients, members, providers and the entire healthcare and benefits ecosystem. Along with leveraging that data for insights, we have decades of experience doing two very important things at scale: mapping healthcare journeys for improved outcomes and cost control, and quoting benefits accurately across millions of member and provider engagements.

We saw an opportunity — a responsibility, really — to combine all that experience into our Large Journey Model. It lets us train GenAI tools like Warrior Assist to help us quickly and accurately solve complex care journey and benefits questions.

Q: How do you address concerns that GenAI might produce inaccurate information or so-called “hallucinations”? 

A: For starters, we have our Warriors intimately involved in designing, training and checking for accuracy any GenAI models we develop. I can’t emphasize enough that we’re using GenAI to empower our Warriors, not replace them.

Also, we use a process called retrieval-augmented generation to carefully control the information and data accessed by a tool like Warrior Assist. It’s not allowed to roam the internet, where it can pick up random, out-of-context information. Instead, Warrior Assist works with client-specific data sources, including the summary plan description and information related to provider networks and ecosystem partners. That prevents hallucinations and ensures the relevance and accuracy of any answer or insight generated.

Q: What has you most excited about future uses of GenAI at Quantum Health?

A: A couple of things. First, the opportunity to empower our Care Coordinators with more time and tools to work at the top of their clinical licensure and benefits training. The more we can take complex or time-consuming tasks off their plates, the more available they’ll be for active listening and proactive problem solving for our stakeholders. It’s that high-touch engagement and deep expertise that makes them such elite advocates for members and effective clinical partners to providers.

Second, we know clients and consultants will continue to pursue innovative plan strategies and specialized care solutions to drive health outcomes and cost control. That means their benefits ecosystems will become more comprehensive going forward. And that means helping plan members navigate their benefits will grow more complex.

Clients need to pursue strategies that produce results. They also need a navigation and advocacy partner that will lean into that, not shy away. As I noted earlier, Quantum Health is purpose-built to remove complexity and cost from healthcare and benefits utilization. GenAI thrives on solving complexity. So, the fit within our platform for GenAI always has been strong. We’re excited about continuing to explore and demonstrate just how powerful it can be.