Provide case management to members including medical, social, psychological, physical, and spiritual needs.
Develop, implement, and monitor the care plan in conjunction with the PCP, caregivers, and other team members.
Help meet the member's needs.
Elderplan and HomeFirst are Medicare and Medicaid managed care health plans that are expanding services in response to patients' needs. At MJHS, they are a supportive community committed to excellence, respect, and providing high-quality, personalized health care services.
Contact patient and complete a thorough assessment, including physical, psychosocial, emotional, spiritual, environmental, and financial needs.
Develop treatment plan for standard and catastrophic cases in collaboration with the patient, caregivers or family, community resources and multi-disciplinary healthcare providers that include obtainable short- and long-term goals.
Advocate for the patient by facilitating the delivery of quality patient care, and by assisting in reducing overall costs; provide patient/family with emotional support and guidance.
Personify Health created the first and only personalized health platform—bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together in one place. They serve employers, health plans, and health systems with data-driven solutions that reduce costs while actually improving health outcomes and have a mission to empower people to lead healthier lives.
Processes acute and post-acute inpatient medical and select intensive outpatient higher level of care requests through clinical review.
Interprets and applies InterQual criteria, CMS-issued guidelines, Capital Blue Cross Medical Policies to requests.
Collaborates with UM department staff and Medical Directors to make a final determination, and with Care Management staff on discharge planning.
Capital Blue Cross is an independent licensee of the Blue Cross Blue Shield Association. At Capital, employees work alongside a caring team of supportive colleagues and are encouraged to volunteer in their community.
Responsible for the Care Coordination staff for case reviews and UR appeals.
Coordinates worklists and completion of cases on audit review, retro authorization and appeals.
Northside Hospital is an award-winning and state-of-the-art healthcare provider that is constantly growing. They are expanding the quality and reach of their care to patients and communities, creating more opportunity for healthcare professionals in Atlanta and beyond.
The Case Manager is a key member of the interdisciplinary care team (ICT).
They use a collaborative process of assessment, planning, coordinating, and monitoring to meet members' health and social needs.
They act as a liaison between Members, their Responsible Parties, the Advance Plan Provider/PCP, and key stakeholders.
Curana Health aims to radically improve the health, happiness, and dignity of older adults. They are a national leader in value-based care, serving 200,000+ seniors in 1,500+ communities across 32 states with a team of more than 1,000 clinicians alongside care coordinators, analysts, operators, and professionals from all backgrounds.
Provide clinical oversight and guidance to CHWs and BHCMs, including escalation support for complex and high-risk patients
Lead clinical case reviews, identifying gaps in care and ensuring care plans are clinically appropriate and aligned with health plan requirements
Support care coordination across medical, behavioral health, and social needs, including collaboration with external providers and hospitals
Zócalo Health is a tech-enabled, community-oriented primary care organization serving people who have historically been underserved by the one-size-fits-all healthcare system. Founded in 2021, Zócalo Health is backed by leading healthcare and mission-aligned investors and is scaling rapidly across states and populations.
Coordinates and oversees all direct and indirect patient services provided by clinical organization personnel.
Provides guidance and counseling to coordinators and Clinical Supervisors to assist them in continually improving all aspects of home health care services.
Assists the Executive Director in the preparation and administration of the organization's budget.
Mission Healthcare, located in seven states, is the largest home health and hospice company in the western United States. They provide services that meet the needs of patients and families across the healthcare continuum and believe their people deserve care delivered with Compassion, Accountability, Respect, Excellence and Service.
Oversee day-to-day operations for the CCPM and TOC care management teams.
Ensure delivery of high-quality longitudinal chronic/complex care management and best-in-class transitions of care.
Continuously evaluate and improve the performance of CCPM and TOC programs and team members.
Evergreen Nephrology partners with nephrologists to transform kidney care through a value-based, person-centered, holistic, and comprehensive approach to kidney care. They are committed to improving patient outcomes and quality of life for patients living with kidney disease. This is achieved by delaying disease progression, shifting care to the home, and accelerating kidney transplants.
Provide exceptional care, disease management and health education to patients
Support goal setting for individual patients asynchronously to help them better manage their chronic conditions
Create personalized action plans with guidelines to reduce or eliminate unwanted behaviors
Salvo is focused on chronic gut health and metabolic conditions from IBS to obesity, assigning patients a care team and providing app-based care seven days a week. Salvo is backed by leading health care investors from innovators; they offer a culture that drives constant innovation and is marked by relentless curiosity and a sense of empathy.
Enhance the quality of member management and maximize satisfaction.
Assist in navigating the health care system as a collaborative health partner.
Promote wellness, problem-solve, and assist members in realization of their personal health-care related goals.
Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence. Driven by empathy and powered by AI and predictive analytics, Guidehealth leverages remotely-embedded Healthguides™ and a centralized Managed Service Organization to build stronger connections with patients and providers.
Facilitate collaboration with health plan care managers
Tuesday Health is a value-based palliative care provider group dedicated to transforming serious illness and end-of-life care. They deliver goal-centered care focused on alleviating physical symptoms and emotional stress for individuals and their caregivers.
Oversees four teams, leading, supporting, and developing them to succeed.
Ensures operational excellence through consistent processes, reporting, and communication.
Drives performance, quality, and continuous improvement across all teams.
BlueCross BlueShield of Tennessee has been helping Tennesseans find their own unique paths to good health since 1945. They empower their employees to thrive both independently and collaboratively, creating a collective impact on the lives of their members.
Deliver coordinated, patient-centered virtual Care Management by telephone or video that improves members' health outcomes.
Help members navigate complex medical conditions, treatment pathways, benefits, and the healthcare system in general.
Assist throughout acute healthcare episodes, such as hospitalizations and rehabilitation stays, providing coordinated Case Management to support the member and their family.
Included Health is a healthcare company that delivers integrated virtual care and navigation, aiming to raise the standard of healthcare for everyone. They break down barriers to provide high-quality care for every person, offering care guidance, advocacy, and access to personalized virtual and in-person care.
Deliver hands-on care navigation services to a diverse patient population.
Partner directly with leadership to design and document care navigation workflows, SOPs, and standards of care.
Contribute to hiring, mentoring, and performance of future team members.
Carewell is dedicated to providing trusted caregiving solutions and support for individuals and families. They extend commitment beyond products to person-centered navigation, care coordination, and advocacy services. Carewell has been recognized as one of the fastest-growing companies in the US.
Coordinate and support the hospital’s Utilization Review and Case Management program.
Review patient charts and clinical documentation to verify medical necessity.
Monitor patient progress and coordinate care management strategies.
NeuroPsychiatric Hospitals is a national leader in behavioral healthcare, specializing in patients with acute psychiatric and complex medical needs. With hospitals in Indiana, Michigan, Texas, and Arizona, they’re expanding access to their unique model of care across the United States.
Coordinate and implement medical case management to facilitate case closure.
Assess appropriate utilization of medical treatment and services.
Review medical records and assess data to ensure appropriate case management process.
Berkley Medical Management Solutions (BMMS) provides managed-care service for W.R. Berkley Corporation, focusing on injured worker’s return to work. BMMS was started in 2014 and combines clinical practices, return-to-work strategies, and software for workers’ compensation cases.
Develop and implement comprehensive plans to drive patient throughput, efficient discharge planning, and readmission prevention.
Provide clinical direction for patient flow and ensure consistent application of systemwide standards and best practices for care coordination.
Leverage deep understanding of local regulations and resources, building relationships with state agencies and community partners.
CommonSpirit Health delivers more than 20 million patient encounters annually through more than 2,300 clinics, care sites and 137 hospital-based locations, in addition to its home-based services and virtual care offerings. CommonSpirit has more than 157,000 employees and contributes more than $4.2 billion annually in charity care.
Acts as primary point of contact for oncology pain patients after referral to the CPC, until the patient has sufficient knowledge and resources to direct self-care.
Responsible for monitoring, coordinating care, and educating cancer patients and families as they move through the CPC.
Responds to criteria-based referrals as soon as possible, no longer than 24 hours, and schedules with appropriate provider within 72 hours.
OHSU is Oregon's only public academic health center that cares for patients, leads groundbreaking research, and trains the next generation of health care professionals. As Portland's largest employer, they offer opportunities to learn and advance in a system of hospitals and clinics across Oregon and Southwest Washington.