Case Management

Members are identified for Case Management through our predictive modeling system, Utilization Management program and Claims and Customer Service areas.  Performing a thorough analysis of prescription drug usage and medical claim information, our state-of-the-art predictive modeling system projects a member’s future burden of illness so that earlier referrals to Case Management can be made.  Earlier referrals help mitigate overall health care costs.

When a plan member is enrolled in our Case Management program, a case manager will work directly with that individual and their health care providers to establish patient-centered goals, managing care across the continuum.  The case manager is dedicated to each case through completion of treatment, centralizes the referral process and concentrates on cases needing additional support.

Measures are taken to help the plan member effectively manage their benefits and medical care to assure the best clinical and financial outcomes.  Case Management programs focus on conditions that may lead to extended, highly specialized or resource-intensive care.  Enhanced case management teams focus on oncology management, transplant care and other specific health care services.