Client Results: Developing a Care Management Program

Delivered key recommendations and implemented target metrics and KPIs that led to formalized processes, staff efficiency and increased productivity.

Challenge

The client needed to enhance and integrate their medical management team and processes. As a part of this, the client also needed to restructure their care management model for their new marketplace insurance product to better serve their membership and to prepare their utilization management, care management and quality teams to meet the new state and federal guidelines.

Solution

ProspHire worked with the client to identify key stakeholders, develop a defined development and implementation strategy, and bring the unique services needed for the defined population. The care management services were focused on improving communication with members, risk stratification methodologies, member tracking and monitoring solutions and providing access to specialized programs in chronic disease management, self-care, and patient education.

Result

ProspHire ensured the client was ready to deliver an integrated care management program focusing on medical, behavioral, pharmacy and social determinants of health needs to their members on day one of the new insurance product with significant time savings and the ability to deliver quality and value for their members.

Deliverables

CM Program
Current state assessment
Standardized processes
Staffing model recommendations

Client Overview

The client is a national managed care and provider organization that provides comprehensive access to healthcare and support services across the country in the commercial, Medicare Advantage and Marketplace arenas.