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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.



To learn more about medical management, check your provider manual (PDF). Or call us at 1-855-221-5656 (TTY: 711). We’re here for you Monday through Friday, 8 AM to 5 PM.

Administración de la atención

Administración de la atención

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

Our care management team supports members based on their personal health risks and unmet needs. 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. 


First, members are assessed by our licensed nurses, social workers, counselors or nonclinical professionals. Then, we use a biopsychosocial model to identify what care members need. Finally, the integrated case manager will do a health risk assessment. This determines the member’s medical, behavioral health and biopsychosocial status.



Care management programs include, but aren’t limited to:


  • Pregnancy outreach
  • Necesidades especiales de atención médica
  • Behavioral health and substance use

Members can self-refer for care management. Or you can refer them. Just call us at 1-855-221-5656 (TTY: 711)

More about care management

Members who are eligible for LTSS will get help from a service coordinator instead of a care manager. The service coordinator will visit the member at home and ask about their health and care needs. 

To decide which services best meet the member’s needs, the service coordinator will work with:


  • The member

  • The member’s primary care provider (PCP)

  • The member’s representative or guardian (if they have one) 


Once they understand what services the member needs, their service coordinator takes care of setting up those services. The member can see their provider for other health care needs. The service coordinator will be there to help them for as long as they stay in the LTSS program. 


Learn more about LTSS

Control de enfermedades crónicas

Control de enfermedades crónicas

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 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 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

More about prior authorization

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
  • Seleccionar las intervenciones más eficaces
  • 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 call us at 1-855-221-5656 (TTY: 711).

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

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