Our case managers are registered nurses. They engage the appropriate internal, external or community-based resources to support the member’s needs. When applicable, we refer to other internal programs such as:
Case management services are voluntary. The member can opt out at any time.
Transitional Case Management (TCM): The collaboration of evaluating and coordinating post-hospitalization needs for members who are at risk of re-hospitalization or frequent users of high-cost services.
General Condition Management: Serves members:
Transplant Resource Services: Members eligible for this program have access to the Optum Center of Excellence (COE) transplant network.
Congenital Heart Disease Program: Members 18 and younger who have a clinical diagnosis of CHD can join. It offers them clinical management and support throughout the process of selecting a facility, being inpatient and experiencing post- discharge.
Cancer Support Program: Covers all types of cancer and provides case management support from an experienced cancer nurse and includes access to cancer COEs.
Bariatric Resource Services: Helps achieve positive results by using evidence-based guidelines and access to a COE/ designated health care provider network of quality bariatric centers to help improve clinical and economic outcomes. It also offers clinical case management by a dedicated nursing staff.
Women’s Health Services: We offer integrated, connected care strategies to positively influence pregnancy outcomes for both mother and the baby.
NurseLine: This program uses a call model and Integrated Clinical User Experience (ICUE) to help facilitate better health outcomes. Each call becomes an opportunity to address a symptom and to connect members with the right care, right health care provider, right medication and right lifestyle.
Emergency Room Decision Support (ERDS): This is a program that helps identify, educate and assist members whose emergency room visits are preventable, avoidable or treatable in a lower-care non-emergency setting.