For Molina Members About Molina
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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 Molina Healthcare case managers are licensed professionals and are educated, trained and experienced in the Case Management process. The CM program is based on a Member advocacy philosophy, designed and administered to assure the Member value-added coordination of health care and services, to increase continuity and efficiency, and to produce optimal outcomes. The CM program is individualized to accommodate a Member’s needs with collaboration and approval from the Member’s PCP. The Molina case manager will arrange individual services for Members whose needs include ongoing medical care, home health care, rehabilitation services, and preventive services. The Molina case manager is responsible for assessing the Member’s appropriateness for the CM 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 to our Case Management Department:

  • Hospitalizations (Primary Diagnoses): Psychiatric, substance abuse, admissions for controllable diseases
  • Social issues: Medical child neglect
  • Life Threatening Chronic Diseases: HIV/AIDS, Cancer, Tuberculosis
  • Members with three or more consecutive missed appointments
  • Significant impairments: hearing, vision, mobility, cognitive/mental impairments
  • Pregnant Patients
  • Members that failed to meet health prevention guidelines
  • Newly diagnosed patients: asthma, diabetes, HIV/AID, mental illness, substance abuse, failure to thrive, low birth weight, critically ill newborn, newborns with NICU stay greater than 24 hours
  • High risk populations that would benefit from Case Management Services
  • Cases identified by PCP, Quality Improvement Department, Complaint or Grievance, Molina Medical Director, Member, Hospital Discharge Planner, Quarterly Administrative Claims Review, New York State Department of Health

 

High risk populations will be discussed quarterly at the QM Committee meetings. Categories for review may be modified depending on the needs of the membership.

Referrals to the CM program may be made by contacting Molina at:
Phone: (877) 872-4716
Fax: (866) 879-4742

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