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Utilization management staff will work with providers on authorization requests submitted via phone, by fax or through the provider portal. They also help providers review clinical guidelines and requests for peer-to-peer reviews. Utilization management staff work with providers to identify discharge plans for members leaving a hospital or facility.
You can find out more about medical management services by downloading our provider manual:
Our care management department supports members based on their personal health risks and unmet needs. First, our members are assessed by our licensed nurses, social workers, counselors or nonclinical professionals. Then, we use a biopsychosocial model to identify what care our members need. Finally, the integrated case manager will do a health risk assessment. This determines the member’s medical, behavioral health and biopsychosocial status.
Care management programs include, but aren’t limited to:
- Pregnancy outreach
- Special health care needs
- Behavioral health and substance abuse
Our disease management program helps with regular communications, targeted outreach and focused education. We help members with specific conditions like:
- Heart failure
- Sickle cell anemia
- Hepatitis C
The main goal of our quality management program is to improve the health status of our members. Our quality management program uses multiple organizational components, committees and performance improvement activities to identify opportunities for success. This allows us to:
- Assess current practices in both clinical and nonclinical areas
- Identify opportunities for improvement
- Select the most effective interventions
- Evaluate and measure the success of implemented interventions, refining the interventions as necessary