Case Management

Case Management Program

The Case Management Program is a service offered to all health plan members which offers support when members are experiencing a critical event, high risk process, or have immediate complex medical conditions or needs. Nurse Case Managers work to identify and resolve care gaps in order to ensure that each member obtains needed services. This occurs at a one-on-one level with nurse support via phone and mail. Case Management frequently assists members with, but not limited to, the complex issues listed below:

  • Wound care requiring extensive treatment
  • Three or more hospital admissions within six months for the same or related diagnosis
  • Major or multiple organ system failure
  • Multiple trauma or acute events
  • Medical/surgical cases with extenuating circumstances
  • Head or spine injuries with potential residual deficits (includes CVAs)
  • Severe burns over 20% or greater of body surface
  • Complicated coordination of care or discharge planning (any disease/condition)
  • Cancer with critical event or treatment requiring extensive use of resources (excludes hospice)
  • Extensive use of healthcare and /or community resources
  • Transplants
  • Post Discharge Support needed from Acute Care Program
  • Obstetrics with focus on high-risk pregnancy for the dual-eligible population

Last updated 10/01/2023