Medical management model

Utilization Management

Our Utilization Management (UM) Program uses an integrated medical management model based on the physical, behavioral and social needs of members. The UM Program, in collaboration with other departments such as Case Management and Disease Management, facilitates the delivery of the most appropriate medically necessary care to members in the most cost-effective, least-restrictive setting.

By collecting individualized data upon enrollment, from historical claims data and through ongoing review, we develop a predictive model that stratifies members into levels of care to determine the appropriate level of intervention. Stratification is refined and targeted to those conditions and episodes of care that are most impactable. Then, member-specific care plans can be developed. Provider(s) are engaged in the development and execution of the plan to ensure that care is integrated across the physical, behavioral and social spectrums.

Care Management Model

Our member-centric care management model integrates behavioral, physical and social factors into each individual member’s plan of care. Our model features the early identification of needs, continuous assessment of health, and a member home approach that promotes collaboration among members, their family, service coordinators, providers and community resources. This approach to care management was specifically designed to meet the needs of Medicaid recipients.

To learn more about our Utilization Management program or our Care Management Model, please see your Provider Manual or contact your Provider Relations representative.