Better care between visits. Better revenue from day one.

CareAtlas embeds dedicated care navigators and clinicians — real people, supported by AI — into your organization to manage RPM, CCM, TCM, and APCM programs. No upfront investment required for hospitals. Practices see revenue from month one. Patients stay healthier at home.

Trusted by health systems. Proven in the real world.

23%

reduction in 30-day readmissions

4+

patient touches per month

30+

vital readings per patient per month

HIMSS26

Emerge Experience Winner's Circle — Hospital Systems category

The care gap is growing

Your patients need more than quarterly visits.

Between appointments, chronic conditions go unmanaged — and the consequences show up as readmissions, declining quality scores, and revenue left on the table.

Human care, amplified by AI

Real people. Real relationships. Real results.

Healthcare doesn't need more technology — it needs more people, supported by technology. Our licensed care navigators build genuine relationships with your patients while AI handles the complexity behind the scenes.

A named navigator for every patient

Your patients get a dedicated care navigator who knows their name, calls them regularly, and helps them manage their conditions. Not a chatbot. Not an app. A person.

AI that works for your team,
not instead of it

HealthQuilt, our proprietary platform, automates documentation, surfaces care gaps, and prioritizes high-risk patients — so navigators spend their time on what matters: patient relationships.

Outcomes that hold up to scrutiny

14.8% readmission rate vs. the 19% CMS benchmark — a 23% relative reduction in a high-risk Medicare population (89% age 65+, 38% COPD, 24% CHF). 73% device adherence. Less than 1% voluntary churn. Results from a 145-patient RPM/CCM cohort, October 2025.

How CareAtlas works

One partner. Four programs. Minimal burden on your team.

CareAtlas manages the full spectrum of Medicare care coordination — RPM, CCM, TCM, and APCM — end to end. We handle enrollment, care delivery, documentation, and billing. Your staff stays focused on what they do best.

Refer

Hospital or clinic refers eligible patients

Enroll

CareAtlas navigators onboard patients with senior-friendly devices (no WiFi needed)

Monitor & Engage

Daily monitoring, regular navigator check-ins, AI-assisted care plans

Document & Bill

Automated compliance documentation and Medicare billing

Report

Clinical insights flow back to the PCP inside their existing EHR

We have a model that fits.

 Every organization is different. CareAtlas offers three models so you get exactly the level of support you need — from full-service to platform-only.

CareAtlas Complete

Full-service care coordination. We provide the navigators, technology, devices, enrollment, billing, and care delivery — end to end. For hospitals, CareAtlas serves as provider of record — no upfront investment required. For practices and community health centers, revenue consistently exceeds program costs.

CareAtlas Extend

Already have some care coordination staff? We augment your team with the HealthQuilt platform, device logistics, and overflow navigator support — filling gaps without replacing what works.

CareAtlas Connect

Platform-only access to HealthQuilt — our AI-assisted care coordination software, EHR integration, analytics, and compliance tools. You bring the team. We bring the technology.

Works with the systems you already use

No new software to learn. No IT projects to manage.

HealthQuilt integrates directly with your EHR. Physicians see CareAtlas insights inside their existing workflow — no separate login, no context switching, no disruption.

Care coordination for every setting

Designed for how healthcare actually works.

Whether you're a community hospital, a multi-site physician network, an FQHC, or a value-based organization — CareAtlas is built for the realities of your practice, not retrofitted from an enterprise product.

Hospital + Health Systems

CareAtlas serves as provider of record through a revenue-sharing partnership — no upfront investment required, no new hires required. We manage RPM, CCM, TCM, and APCM across service lines, reduce readmissions, and generate net-new Medicare revenue. Proven in community and rural settings.

Physician Practices

Generate $50–$120 per patient per month in new Medicare revenue without adding staff or complexity. We handle enrollment, monitoring, documentation, and billing. You keep the patient relationship and stay provider of record.

Revenue varies by program mix, volume, and payer. Not a guarantee of income.

Community Health Centers

One platform for FQHCs and RHCs to run multiple virtual care programs. No broadband required for patients. Full support for the current standard CPT billing codes. APCM-ready from day one.

Value-Based Organizations

Better population health data, more efficient care triage, and measurable HEDIS and Star rating improvement. CareAtlas scales across your network to reduce total cost of care and close chronic disease care gaps.

What's your untapped Medicare revenue?

Input your patient volume and care setting. See the revenue CareAtlas can help you capture — with the math behind it.

Full-spectrum care coordination

Four programs. One partner. Every eligible dollar captured.

Most organizations cobble together multiple vendors for RPM, CCM, TCM, and APCM — or leave the revenue on the table entirely. CareAtlas manages all four under one roof, maximizing reimbursement per patient.

Remote Patient Monitoring

01

RPM: Daily visibility into patient health

Cellular-connected devices ship directly to patients — blood pressure cuffs, glucose monitors, pulse oximeters, scales. No WiFi. No smartphone. No patient app. Daily readings are monitored by dedicated care navigators with AI-assisted alerts that catch deterioration before it becomes an ER visit.

Chronic Care Management

02

CCM: Consistent care between appointments

Monthly navigator check-ins, personalized care plans, medication management, and social determinant screening — all documented and billed under 99490/99491. Only 4% of eligible Medicare patients are enrolled nationally. CareAtlas closes that gap.

Transitional Care Management

03

TCM: The critical 30 days after discharge

Navigator outreach within 48 hours of discharge. Medication reconciliation. Follow-up scheduling. 30 days of transition support during the window when patients are most vulnerable — and when the vast majority of billable TCM episodes go uncaptured. Only ~9% of eligible Medicare discharges result in a TCM bill, and among those unbilled, over half already had a qualifying office visit within 14 days — revenue left on the table.

Advanced Primary Care Management

04

APCM: The newest Medicare revenue pathway

APCM reimburses across three risk-stratified tiers — $16/mo (Level 1), $54/mo (Level 2), and $117/mo (Level 3) — with no time-tracking requirements. For a panel of 200 patients at Level 2, that's ~$129K/year in recurring revenue, billable alongside RPM.

"CareAtlas is superior to what I currently use, our existing platform is just a timer and a billing module. CareAtlas really integrates into my workflow, brings in relevant data and meaningfully suggests insights”

Physician

Texas-based Health System

Common questions from providers

We know outsourced care coordination raises fair questions. Here are the ones we hear most.

Let's keep your patients healthier between visits.

Schedule a 15-minute call to see how CareAtlas works for your organization — and what revenue you may be leaving on the table.

Woman in yellow blazer smiling and using a laptop, with another person blurred in the foreground in a modern office setting.