Medical Management

Our Utilization Management team members include a Medical Director who is licensed in the State, as well as a panel of physicians, nurses, and paraprofessionals at the administrative offices whose specialties balance today’s increasing demand for specialized health care knowledge today. As diseases and conditions grow more complex with respect to origin and treatment, our Utilization Management team responds to coordinate not only the medical care needed by our members, but also collaborates with our Special Needs Unit and Case Management Department to ensure that the special needs of our members are met. Often, our Medicare members require services that are not contract benefits or are community–based services. The Special Needs Unit will coordinate those services and work closely with community based organizations to maximize health care outcomes.

Disease management programs include diabetes; asthma/COPD; hypertension. Care Coordination or Case Management Support is offered for Mental Retardation/Developmental Disabilities, Adult/Aging/Rehabilitation, wound care, and HIV/AIDS Services. Additional or different programs may be developed as indicated through subsequent analysis of a state’s population.