Our Case Management services include Level 1, for those with medical conditions that are not critical in nature, and Level 2, for those with serious conditions.
When we identify members who are candidates for Case Management and they elect to receive the service, we can intervene and help manage their condition and treatment. We also offer reminders that encourage members to contact us when they feel case management is appropriate.
In Level 1, our Case Management nurses contact members after a discharge from a hospital or after an outpatient procedure to:
- determine how the person is fairing
- inquire about prescriptions being filled
- answer questions
- help with follow-up services
This service is very popular, especially with new mothers.
In Level 2, where a member may be experiencing a complex or catastrophic illness, our nurses are in close and constant communication with the member to offer support and expertise, work closely with healthcare providers, and coordinate care throughout a wide scope of services.
Candidates for Level 2 can be identified several ways:
- prior to a claim submission, through the pre-certification process
- after a claim is received and reviewed by a health facilitator
- when referred directly by a wellness program nurse
- through stop loss reporting
For both levels, early intervention allows us to be of the greatest help by obtaining the best outcome for the patient and best value for the plan.