Health Management

Utilization Review

Our Utilization Review program prior authorizes hospital admissions and certain treatments and procedures. This is to give you access to high-quality health care services. Our Utilization Review team is made up of dedicated nurse care managers and medical directors.

Concurrent Review

During your hospital stay, a case manager works directly with your doctor and the hospital to make sure you get the care you need.

Discharge Planning and Follow-Up

A case manager works with your health care team throughout your hospital stay. A discharge plan is made with you, your family, your doctor, the hospital and other health care providers to make sure the best plan is made so you have a smooth transition home or to another facility.

Total Joint Replacement Program

Get the information and services you need to focus on preparing for and recovering from surgery. The program teams you, your family and doctor with a nurse care manager who can answer health and benefits questions and coordinate your care during recovery.

If you or a family member suffer from a chronic condition like asthma, diabetes, coronary artery disease, heart failure, chronic obstructive pulmonary disease or kidney disease, this voluntary program can help you achieve your personal health goals and manage your health. Dedicated nurse care managers work with you, as well as your doctors, to help you carry out your doctors’ individual plan of care. To speak with a ConditionCare nurse, call 1-866-596-9812.

Advanced imaging tools like CT scans and MRIs can really help identify underlying health problems. But the American College of Radiology estimates that 20-30 percent of these tests are not medically necessary or are duplicative.¹ Unnecessary imaging may contribute to two patient safety issues: increased radiation exposure and false positive findings that may result in additional testing and potential surgical procedures. To help make sure you receive services that are safe and appropriate, we work with your doctors to determine if the imaging recommended is an appropriate choice for diagnosing the problem at hand.

We belong to the Blue Distinction Transplant Center network to help you access the highest level of care available. Blue Distinction Transplant Centers are designated facilities that meet stringent quality criteria, as established by national organizations and expert clinician panels.

If you’ve got multiple health care issues and are at risk for needing frequent and high levels of medical care, this program may be for you. Our goal is to help you access quality care, learn to effectively manage your conditions and lead the healthiest life possible. You get a nurse care manager who works closely with you and your doctor to:

Create an individualized care plan

Develop personalized goals

Coordinate care

If your newborn is in the neonatal intensive care unit, this program can help. A specialized team of nurse care managers and medical directors work with you, your family and doctors to make sure your baby receives the best care possible.