Medical Case Management Programs
Our comprehensive Medical Management programs start with a human connection and give you more control over the quality of care for patients. Our programs offer personalized support through utilization management, case management, disease and chronic care management and wellness.
Utilization Management
We will determine which services are medically appropriate and necessary. We do so with mix of evidence-based clinical guidelines, benefit tiering and prior authorization data. We can monitor claim activity to identify recurring or expensive claims. We also redirect services to improve the quality of care and reduce costs.
Case Management
When members have complex and catastrophic medical conditions, they often need extra input and care. Our highly trained nurse counselors proactively reach out to members who need additional attention and would benefit from individualized case management.
Disease and chronic care management
Whether it’s one disease or multiple chronic conditions affecting a patient, we can determine if they are high risk and reach out to ensure they get the care they need. We will run claims, look at the care members have received in the past, and coach these members through chronic and complex health issues and make sure they’re supported in managing their conditions.
Wellness
Making sure members are healthy matters more than anything. We believe prevention starts with primary care. We identify gaps in care, assist members in receiving the appropriate preventive care they need, and help them establish a relationship with their primary care provider. We’ll also work to promote incentive programs, send out wellness newsletters, provide prevention education, and ensure members have access to vital behavioral health services.
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