Services That Meet Members Where They Are

Our certified case managers provide individualized, long-term support for members with complex medical and social needs. Starting with a thorough clinical assessment, each case manager develops a personalized care plan, identifies barriers, and coordinates resources across the full care continuum. Regular touchpoints ensure goals stay on track and the plan evolves with the member's condition.

Effective care requires seamless communication between every party involved. We act as the connective tissue between primary care, specialists, behavioral health, pharmacy, and community resources. Our coordinators facilitate referrals, close communication loops, reduce duplicative testing, and prevent dangerous gaps between providers.

Families navigating a NICU stay face clinical uncertainty, financial stress, and overwhelming decisions. Our NICU case managers provide support from admission through discharge and into the first months at home. We coordinate between the medical team and family, arrange durable medical equipment, facilitate early intervention referrals, and ensure the discharge plan is realistic and supported.

Pregnancy carries heightened risk for members with chronic conditions, social determinants of health, or prior adverse outcomes. Our maternal health program pairs high-risk mothers with a dedicated care manager throughout pregnancy and into the postpartum period. We focus on prenatal compliance, mental health screening, social support, and facilitating a safe, supported transition after delivery.

Children with complex medical conditions, developmental delays, or special health care needs require coordination that spans medical, educational, and community systems. Our pediatric care managers work with families to navigate specialty care, early intervention programs, school accommodations, and developmental resources, helping each child reach their full potential.

Transitions between care settings are among the highest-risk moments for Medicare beneficiaries. Our care transitions program follows members from hospital discharge through the first 30 days at home or in a post-acute facility. We reconcile medications, confirm follow-up appointments, identify early warning signs, and maintain contact with the primary care provider to prevent unnecessary readmissions.

Living with a chronic condition requires more than a prescription. Our disease management programs for diabetes, COPD, heart failure, hypertension, and asthma combine regular outreach, structured education, and clinical monitoring to help members understand their condition, manage it day to day, and avoid preventable crises. Programs are evidence-based and adaptable to each member's health literacy and readiness to change.