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Medical management

The goal of our medical management team is to promote cost-effective care that helps members be as healthy as they can be. This means working with providers to assess conditions, create care plans, coordinate resources and check progress.

Contact us

To learn more about medical management, check your provider manual (PDF). Or call us at 1-855-300-5528 (TTY: 711). We’re here Monday through Friday, 7 AM to 7 PM ET. 

Care management

Care management

Our care management team supports members based on their personal health risks and unmet needs. A care manager is assigned to each member. They’re part of the medical management team. And their job is to make sure members get all the care and services they need. 


First, members are assessed by our licensed nurses, social workers, counselors or nonclinical professionals. Then, we use a biopsychosocial model to identify what care 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


Questions about care management? Just email us.

Disease management

Disease management

The disease management program helps with regular communications, targeted outreach and focused education. We help members with specific conditions, like:


  • Diabetes

  • Asthma

  • Heart failure

  • Sickle cell anemia

  • Hepatitis C

  • Obesity

  • HIV/AIDS  

Utilization management (UM)

Utilization management (UM)

The UM team will help providers: 


  • Complete authorization requests submitted by phone, fax or Provider Portal

  • Review clinical guidelines and requests for peer-to-peer reviews

  • Identify discharge plans for members leaving a hospital or facility

Quality management (QM)

Quality management (QM)

The main goal of this program is to improve the health status of members. Our QM program uses multiple organizational components, committees and performance improvement activities to find opportunities for success. This allows us to:


  • Assess current practices in both clinical and nonclinical areas

  • Identify areas for improvement

  • Select the most effective interventions

  • Evaluate and measure the success of implemented interventions, refining them as necessary


The Healthcare Effectiveness Data and Information Set (HEDIS) is a widely used performance improvement tool. Visit our HEDIS page for more info.


The state assigns a risk score to health plans based on the number and type of chronic conditions members have. Accurate risk scoring requires these conditions to be documented in claims.


Learn more

Just download our provider manual (PDF) for more info about medical management.


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