Case Management

Our goal is to advocate for members and promote high-quality, cost-effective outcomes 

Strong coordination of services is vital to efficient care and positive outcomes.

The complexities of a critical illness can make it especially challenging to “connect the dots” between members and their various care providers. Case management excels at this through direct, effective interaction every step of the way. It supports the most costly segment of members – those with high-cost acute conditions or complications requiring intense case management for a short period of time. Our nurse Care Managers coordinate the care and services from the point of diagnosis or hospital admission through the follow-up process in the community. Candidates are typically identified through utilization management referrals, system triggers for diagnosis, readmission and length of stay, or as a result of our analysis using a predictive modeling program based on claims data.

 

Care Managers coordinate complex medical needs to:

  • Monitor participant progress and adherence to the physician’s plan of care
  • Identify and pursue cost containment opportunities
  • Facilitate discharge planning to identify the appropriate setting and continuation of care needs, and monitor anticipated recovery milestones
  • Refer members to the appropriate condition management program as needed
  • Provide education and support

 

Specialized nurse Care Manager support 

Health Plans provides the expertise of a clinical nurse Care Manager expert to educate, monitor and support participants. Specialties include oncology, transplant, rehabilitation, medical-surgical, behavioral health, pediatrics and high-risk maternity. Care Managers work collaboratively with participants and caregivers to:

  • Help understand diseases, treatment options and benefits
  • Assist in navigating the health care system
  • Educate about symptom management, safety and prevention of complications
  • Provide emotional support and recommend community service and support groups