Care Management Department
Utilization management (UM), case management and health management activities comprise a comprehensive care management program, and are integrated with clinical quality improvement activities. All Care Management and quality improvement activities report through the same committee structure, and all staff ultimately report to the Chief Medical Officer for clinical issues and the Vice President of Care Management for all administrative issues.
UM activities within care management include prior approval, concurrent review, retrospective review,
discharge planning, chart audit and medical claims review for medical/surgical
and mental health/substance abuse services.
Case management is a multidisciplinary process and involves the coordination of complex care needs while facilitating flexible, individualized plans of care and utilizing community resources. This process is a collaborative effort between the member, family, physician and other members of the healthcare delivery team. The case management process provides cost-effective options for selected members with complex medical and social needs.
Health management activities include identification of eligible members, completion of needs assessments, determination of the appropriateness of services, formulation of an individualized plan of care, implementation of services, measurement and evaluation of the plan of care, and a program evaluation. offers several health management programs to assist members with a chronic disease or pregnancy.
Reports focused on care management activities are generated on a routine basis and are utilized to assess the effectiveness, appropriateness, and efficiency of the care management program.
Contact the Care Management Department.