Care Coordination & Patient Advocacy
Secure Health’s care coordination and patient advocacy services are fully integrated with our member services and claims administration systems, which creates seamless member management. Our expert medical staff is comprised of Registered Nurses (RN), Licensed Nurse Practitioners (LPN), Certified Case Managers, and a Board Certified Physician, all of whom understand benefits, claims, and network plans, including multi-tiered benefits and PPO networks.
Our Utilization Management (UM) department has been accredited by the Utilization Review Accreditation Commission (URAC) since 1998. We conduct medical necessity reviews for elective and urgent or emergent inpatient admissions, as well as for select outpatient services. Our UM services make best efforts to ensure:
- Member eligibility
- The service requested is covered by the member’s health plan
- The procedure is medically appropriate
- The member is seeking care within the preferred network
We review cases on a prospective, concurrent, and retrospective basis prior to processing a claim for payment in order to ensure claims dollars are spent wisely.
Complex Case Management
Our Complex Case Management team assesses and plans for your members’ care. It is through a collaborative process whereby we assess a patient’s needs and initialize a care plan, and then coordinate, monitor, and evaluate the services and procedures available to meet a member’s health needs.
Case management nurses perform several services:
- Educate patients on their condition
- Encourage medical compliance
- Ensure transplant network agreements are in place for potential transplant candidates
- Assist with follow-up appointments
- Assist with reinsurance coordination
- Negotiate with out-of-network providers
- Coordinate aggressive cost containment for dialysis services
Secure Health’s Medical Review services ensure claims presented for payment are covered by a patient’s plan and are not considered experimental, investigational, or cosmetic. Our team fully understands safety, efficacy, and cost and stays current with new health plan trends. This expertise, along with access to numerous medical databases, allows us to make sound medical necessity and coverage decisions regarding the latest medical treatments, procedures, drugs, and services.
Transitional Care Management
Quality care does not end upon discharge. Our Follow Me Home Program improves the quality of care for members by focusing on the critical transitional period from acute care to care in the home. Transitional care management services assist in avoiding unnecessary hospital readmissions and emergency department visits. Our transitional care managers help patients in several ways:
- Helping patients understand their health conditions and the reason for their hospitalization
- Recognizing potential complications early and coordinating additional care
- Scheduling follow-up appointments
- Prevent avoidable emergency room visits and readmissions
- Ensuring patients understand their discharge instructions and continued outpatient care needs