How Utilization Management Helps You
As part of our Utilization Management/Quality Improvement program, a team of nurses reviews and monitors your treatment before, during, and after your hospital stay. Their job is to verify whether services are covered and delivered in a timely, medically necessary, quality-oriented, cost-efficient manner. This monitoring process is called Utilization Management.
Concurrent Review Process
Concurrent means “happening at the same time.” Concurrent review nurses perform this review either by telephone or by visiting the hospital during your treatment. During the concurrent review process, our nurses and medical directors continually monitor the medical necessity and level of care provided to members while they are in the hospital. Concurrent review is performed for all members hospitalized in an acute, rehabilitation, subacute, or skilled nursing facility.
Nurses help with discharge planning needs for members to assure a smooth transition of care. Members with complex needs may be referred to Complex Case Management for on-going support.
This process includes a review of any service that a member has already received. It’s another example of our commitment to our members for getting appropriate care.
Complex Case Management
Complex Case Management
Coventry Health Care members have access to unrivaled Complex Case Management, a collaborative process between Coventry Health Care, the member and their health care provider. It is designed to assess, plan, implement and evaluate the services required to meet an individual’s health care needs, using available resources as necessary. This process is aimed at producing the highest quality outcomes in the most efficient, cost effective manner for both the member and Coventry Health Care.
Our Complex Case Management program is staffed by registered nurses who have an understanding of the case management process, health care management, service delivery, awareness of cultural diversity and community resources and support. Complex Case Managers are encouraged to continue their professional development by obtaining certification as a certified case manager, attending classes offering continuing education credits/certified case management credits and attending relevant seminars.
Coventry Health Care’s Complex Case Management program is a telephonically managed care model, supported by written communication for education or reference. The program is designed to assist members with complex, chronic or catastrophic illnesses to enhance the coordination, continuity, and quality of care. Complex Case Managers focus on:
- Engaging members and building trust through superior customer service
- Collaborating with the member, family, caregiver and provider to ensure they understand and use resources available within Coventry Health Care’s network, as well as understanding their health insurance benefits and any financial responsibility that may belong to the member
- Influencing behaviors through education and ensuring compliance with the provider’s treatment plan
Members who may benefit from Complex Case Management services are identified through Coventry Health Care’s utilization review process and utilization flags. In addition, members are referred for Complex Case Management evaluations from other Coventry Health Care departments such as Disease Management and Customer Service. Members also may be referred for an evaluation by their employer group, Coventry Health Care providers or by self-referral. For more information, please contact:
Customer Service toll-free (800) 431-1211
8 a.m. to 6 p.m. Monday through Thursday
8 a.m. to 5 p.m. on Friday