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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 1-855-232-3596 (TTY: 711). 

Identifying members

Identifying members

We use several sources to identify members for care management and disease management:


  • Enrollment data from the state
  • Predictive modeling tools
  • Claim/encounter info, including pharmacy data, if available
  • Data collected through the utilization management process
  • Lab results
  • Hospital or facility admissions and discharges
  • Health risk appraisal tools
  • Data from health management, wellness or health coaching programs
  • Provider referrals for members who act inappropriately or are disruptive or threatening in the office

You can call or email the Care Management Team with questions:


Malvina Williams
Supervisor, Clinical Health Services


Ann Marie McGinnis
Supervisor, Clinical Health Services


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
  • Nonclinical professionals

Then, we use a biopsychosocial model to identify what care members need. Finally, the care manager will do a health risk assessment. This determines the member’s medical, behavioral health and biopsychosocial status.


Do your patients need care management?

We can help your patients with certain conditions enhance their self-management skills. This includes conditions like:


  • Chronic obstructive pulmonary disease (COPD)
  • Congestive heart failure
  • Coronary artery disease
  • Diabetes
  • Other conditions


Care management programs may also include topics like:


  • Pregnancy outreach and high-risk obstetrics (OB)
  • Special health care needs
  • Behavioral health and substance abuse


Care managers educate members about their condition and how to prevent worsening of their illness or any complications. The goal is to maintain, promote or improve their health status.


To create a quality-focused, cost-effective care plan, care managers collaborate with:


  • The member
  • Member’s family
  • Primary care provider
  • Psychiatrist
  • Substance abuse counselor
  • Other health care team members


To identify members that are the right fit for care management, we may use referrals from:


  • Our health info or special needs lines
  • Members
  • Caregivers
  • Providers
  • Practitioners


Integrated care management means your patient only has one care manager, even if they also take part in:


  • Care Management
  • Condition Management

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


  • Asthma
  • COPD
  • Heart failure (HF)
  • Diabetes
  • Hypertension

After we identify members as having one of these conditions, we automatically enroll them in disease management. So they don’t have to actively enroll. We’ll let you know they’re taking part and work with you to reinforce their treatment plan.


Our disease management programs help members stay healthy. They learn about their health conditions and how to stay well by working with you. We want to educate and support members, as well as prevent their condition from getting worse. Giving members the tools they need to better manage their health can reduce:


  • Hospitalization
  • High use of health care resources 

Dedicated care management is here for members who are elderly or disabled. This includes members eligible for managed long-term services and supports (MLTSS). These members have special service needs and risks, such as: 


  • The need for more services to improve and maintain quality of life
  • Increased risk for institutionalization
  • Increased risk of falls, injuries (including fractures) and adverse events
  • Increased risk of cognitive impairment
  • Higher prevalence of polypharmacy and medication interactions
  • Risks for abuse, neglect and exploitation
  • Higher vulnerability to influenza and pneumococcal disease
  • Under-recognition and under-treatment of depression
  • Need for cancer surveillance


Our programs enhance members’ quality of life and ensure optimal health outcomes. These programs include:


  • Evidence-based guidelines
  • Focused education of members, caregivers and providers
  • Review of data that tells us how members are doing

Our goals include ensuring that members get appropriate testing and care for their special needs. We want to help members:


  • Reduce avoidable complications of chronic illness, such as diabetes, HF, COPD, hypertension and seizure disorders
  • Support early diagnosis of cancers of the breast, cervix, colon and prostate
  • Reduce injuries, pressure ulcers and aspiration pneumonia
  • Reduce avoidable hospitalizations, including those that can be prevented by vaccination for influenza and pneumococcal disease
  • Support early recognition of depression and cognitive impairment
  • Prevent or reduce injuries
  • Maintain quality of life and independence as much as possible
  • Decrease or prevent long-term institutionalization
  • Prevent and identify abuse, neglect and exploitation
  • Improve quality of care
  • Help caregivers with support and resources


National recommendations and educational materials are available through the National Institute of Health’s National Institute on Aging.


In addition to news items, you can find publications for physicians and other providers. You can also find multiple health topic booklets relevant to our members who are elderly or disabled: 


We hope you find these resources helpful and we look forward to continued collaboration with you to enhance the well-being of these members.

A fall can have a significant impact on members. They can have a fall at home, in the workplace, in an acute care setting or in a long-term care facility. Falls are the leading cause of fatal injury and the most common cause of nonfatal trauma-related hospital admissions among older adults. Members aged 85 and older are up to 15 times more likely to break a hip from a fall than those aged 60 to 65 years.


The elderly are more vulnerable to falls than any other age group. But all members can benefit from education about precautions to make homes, hospitals and workplaces safe and free from falls.


Use of certain prescription medications and polypharmacy may make patients unsteady, possibly leading to falls. Try reviewing medications with your patients. Then, suggest these precautions to prevent falls:


  • Wear sturdy shoes that have non‑slip soles.
  • Always use a handrail when climbing up or down stairs.
  • Keep doorways and floors free of obstacles such as throw rugs and furniture.

State law P.L.2019, c.88 mandates the completion of a PRA form for pregnant women receiving state-supported Medicaid health coverage.


The law began in the state Legislature as Senate Bill 3406 as a package of bills designed to improve the health of expectant mothers and newborns. The goal is to decrease rates of maternal and infant mortality in New Jersey. The PRA form is now required documentation for all uninsured, Medicaid presumptively eligible, and Medicaid-eligible prenatal patients. This law impacts obstetric (OB) providers, nurse midwives and other licensed health care providers.


What do OB providers need to do?

OB providers need to submit the required PRA form for reimbursement of OB services. If we don’t receive the forms, you may not receive payment.


If you’re a prenatal care provider, you’ll want to register with Family Health Initiatives (FHI) to access the PRA/SPECT. You can register:



Complete and submit the:


  • Initial visit PRA form during the first prenatal visit
  • Follow-up visit PRA form when there is a change in insurance or you identify a maternal risk factor
  • Third trimester visit PRA form at 30 to 36 weeks gestation


Just log in to to submit your forms. 


Learn more

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


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