Utilization management describes proactive procedures, discharge planning, concurrent planning, precertification, and clinical case appeals. It is used to balance quality, risk, and cost concerns in the provision of patient care. The goal of UM is to maintain the quality and efficiency of health care delivery by ensuring patients are receiving care at the appropriate level, by coordinating health care benefits, and ensuring the least costly but most effective treatment benefit. This goal is accomplished with the use of nationally accepted clinical practice guidelines. Utilization Management reviews are performed by Registered Nurses with diverse clinical backgrounds. Nurses working in UM frequently have medical-surgical experience and have moved into the UM role due to the desire to move from direct patient care and/or to a position that offers more stable weekday hours than a clinical setting
Case Management is the coordination of care and services to a specific population. It is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet a patient’s healthcare needs through communication and identification of available resources to promote quality and cost-effective outcomes. Carewise Health’s Case Management Program (CM Program) uses a telephonic approach and strives to ensure the provision of high quality, efficient, appropriate, and medically necessary continuum of care management in the most overall effective setting for patients who have complex care requirements for high intensity, intermediate, or long term delivery of health care services. CM staff conducting case management is licensed registered nurses with clinical expertise in a variety of specialized areas, i.e., cardiac, immune, endocrine, neurological, transplant, cancer, musculoskeletal, and respiratory. They have worked at the bedside in these specialty areas, worked as case managers and discharge planners in the hospital and/or worked at home health agencies. Staff is expected to obtain CCM certification.
Carewise Health’s Disease Management Program (DSM Program) uses a telephonic approach to help empower consumers to make better decisions, live healthier lifestyles, and more efficiently navigate the healthcare system leading to improved health and productivity, and effectively manage healthcare costs. DSM staff conducting disease management is licensed registered nurses with clinical expertise in general medical and surgical areas. They have worked at the bedside or in a physician’s office. The nurses are expert and can teach to the evidence–based practice guidelines for each disease state helping members understand the progressive nature of their conditions. Some staff members are certified diabetic educators.
Our Wellness team is staffed by a diverse team of specialists:
- Health Educator with Bachelor Degrees
- Specialists with degrees and stidies in Nutrition, Exercise, Diabetes, Hypertensions, Hyperlipidemia, Obesity, Stress Management and Smoking Cessation
- The Wellness team is part of the clinical team of Medical Directors, Registered Nurses, Case Management Nurses, Utilization Nurses, and Maternity Nurses to deliver proactive condition management