Case management - Chapter 13, 2022 UnitedHealthcare Administrative Guide

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:

  • Disease management.
  • Complex condition management.
  • Behavioral health employee assistance.
  • Disability.

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:

  • With chronic conditions.
  • In need of long-term care support.
  • Who have unmet access.
  • Who have care plan, psycho-social, or knowledge needs.

Commercial complex medical conditions programs

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.

  • Our fertility, maternity and neonatal care management programs support members with appropriate guidance, education, and counseling. Members with unique health needs and high-risk pregnancies receive personalized case management support to minimize pregnancy complications.
  • Our easy-to-access, multimodal channels allow members to remain engaged with their care team. The new UnitedHealthcare Healthy Pregnancy App delivers personalized content, helps determine risks, and facilitates maternity nurses’ support and care during pregnancy.

Decision support program

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.