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Case Management and Complex Case Management

Case Management

Molina Healthcare provides a comprehensive Case Management (CM) program to all Members who meet the criteria for services. The CM program focuses on procuring and coordinating the care, services, and resources needed by Members with complex issues through a continuum of care. Molina Healthcare adheres to Case Management Society of America Standards of Practice Guidelines in its execution of the program. The CM program is individualized to accommodate a Member’s needs with collaboration and approval from the Member’s PCP.

The Molina Healthcare case managers are licensed Registered Nurses (RNs) and are educated, trained and experienced in the case management process. The case manager will arrange individual services for members whose needs include ongoing medical care, home health care, rehabilitation services, and preventive services. The case manager is responsible for assessing the member’s appropriateness for the program and for notifying the PCP of the evaluation results, as well as making a recommendation for a treatment plan.

Members with the following conditions may qualify and should be referred for evaluation:

  • High-risk pregnancy, including Members with a history of a previous preterm delivery
  • Catastrophic medical conditions (e.g. neoplasm, organ/tissue transplants)
  • Chronic illness (e.g. asthma, diabetes, End Stage Renal Disease (ESRD))
  • Preterm births
  • High-technology home care requiring more than two weeks of treatment
  • Member accessing ER services inappropriately

Complex Case Management

Molina Healthcare offers you and your patients the opportunity to participate in our Complex Case Management Program. Patients appropriate for this voluntary program are those that have the most complex service needs and may include your patients with multiple medical conditions, high level of dependence, conditions that require care from multiple specialties and/or have additional social, psychosocial, psychological and emotional issues that exacerbate the condition, treatment regime and/or discharge plan.

The purpose of the Molina Healthcare Complex Case Management Program is to:

  • Conduct a needs’ assessment of the patient, patient’s family, and/or caregiver
  • Provide intervention and care coordination services within the benefit structure across the continuum of care
  • Empower our patients to optimize their health and level of functioning
  • Facilitate access to medically necessary services and ensure that they are provided at the appropriate level of care in a timely manner
  • Provide a comprehensive and on-going care plan for continuity of care in coordination with you, your staff, your patient, and the patient’s family.

If you would like to learn more about these programs, speak with a case manager and/or refer a patient for an evaluation, please contact Molina Healthcare at 1-888-999-2404.

*Printed copies of information posted on our website are available upon request.

 

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