ProspHire developed a Care Management Program that included delivering key recommendations to formalize processes, managing staffing efficiency and increasing productivity by implementing target metrics and KPIs.

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.

Outcomes

  • 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.

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Deborah Holzmark

Chief Clinical Officer
Name

Clinical Services Optimization

ProspHire’s team of clinicians help organizations optimize processes to improve health outcomes. We have deep subject matter expertise in care management (CM), utilization management (UM), value-based care (VBC), social determinants of health (SDOH) and population health reporting. We are adept at addressing patient experience challenges, throughput optimization and clinical resource management. Our demonstrated results lead to increased profit, enhanced operational efficiency, improved clinical outcomes and a better patient and provider experience.