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The goal of our medical management team is to promote cost-effective care that helps members be as healthy as they can be. This means working with providers to assess conditions, create care plans, coordinate resources and check progress.

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To learn more about medical management, check your provider manual. Or contact us.

Care management

Care management

Our goal is to improve access to quality care and avoid unnecessary medical costs. We try to help with the efficient use of medical resources for members with special health care needs, including complex, chronic and catastrophic cases.

We identify members who might benefit from care management through:

  • Utilization management activities
  • Health risk assessments
  • Screening of administrative data
  • Provider and member notification

Our care management team supports members based on their personal health risks and unmet needs, including social determinants of health. A care manager is assigned to each member. They’re part of the medical management team. And their job is to make sure members get all the care and services they need.

All members are asked to complete a health risk screening with our onboarding team. The member is then risk stratified based on physical, behavioral and social determinants of health needs. After the member agrees to care coordination, the member is assigned a registered nurse or behavioral health specialist to support their health goals.

What programs does care management include?

All members have the ability to be in care coordination. We outreach to target specific populations, including those who:

  • Are pregnant
  • Have special health care needs
  • Need behavioral health care
  • Have sickle cell disease, elevated blood lead levels, chronic conditions and members eligible for PrEP (pre-exposure prophylaxis)
  • Need support with obtaining durable medical equipment

Medicare-Medicaid plan care management programs include, but aren’t limited to:

  • Long-term services and supports (LTSS) (examples: home health or personal care aide)
  • Waiver services (examples: home-delivered meals, non-emergency rides, chore services and specialized equipment)
  • Pregnancy outreach
  • Behavioral health and substance use
  • Support with obtaining durable medical equipment
  • Community transition support

Chronic disease management

Chronic disease management

The chronic disease management program helps with regular communications, targeted outreach and focused education. We help members with specific conditions, like asthma and diabetes.


Members get education, coaching and other services to help them manage their condition. They also receive help from disease management nurses. These nurses perform or facilitate health risk assessments. They can also create an action plan based on the member’s:

  • Understanding of their condition

  • Need for equipment and supplies

  • Referral for specialty care or other special considerations due to comorbidities, including behavioral health and substance abuse

More about Medicaid chronic disease management

More about Medicare-Medicaid plan chronic disease management

Utilization management (UM)

Utilization management (UM)

The purpose of UM is to manage the use of health care resources to ensure that members get the most medically appropriate and cost-effective health care. The goal? Improving medical and behavioral health outcomes. 


The UM team will help providers:

  • Complete authorization requests submitted by phone, fax or through the Provider Portal

  • Review clinical guidelines and requests for peer-to-peer reviews

  • Identify discharge plans for members leaving a hospital or facility

Quality management (QM)

Quality management (QM)

The main goal of this program is to improve the health status of members. Our QM program uses multiple organizational components, committees and performance improvement activities to find opportunities for success. This allows us to:

  • Assess current practices in both clinical and nonclinical areas

  • Identify areas for improvement

  • Select the most effective interventions 

  • Evaluate and measure the success of implemented interventions, refining them as necessary

The Healthcare Effectiveness Data and Information Set (HEDIS®) is a widely used performance improvement tool. Visit our HEDIS page for more information.

We have a comprehensive ongoing Quality Assessment and Performance Improvement (QAPI) program that:

  • Focuses on the quality of clinical care and services to our members

  • Helps ensure that members get preventive health care in a timely manner 

  • Provides care management services to people with special health care needs 

  • Adheres to state and federal requirements 

  • Is overseen by the Governing Board of Directors and Quality Oversight Committees  


Performance improvement and measurement are fundamental to the QAPI program. We can’t improve what we don’t measure. So we analyze encounter data to identify gaps in care and recommend opportunities for improvement. Your involvement, feedback and recommendations for improving the delivery of care and services are welcome. Just contact us.

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

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