Nurse Case Management

“Getting the most out of your healthcare investment.”

Spending several million dollars on healthcare and then “hoping for the best” is not the best strategy. There are a number of efforts put forth to reduce the amount spent by a plan, e.g. networks, Utilization Review, pharmacy controls, etc. Another very important effort is nurse case management.

Group Health programs generally don’t have adjusters like other insurance programs have. Most often they have claims processors, but for the most part, there is no one to ensure that the care a patient receives is timely, effective, and coordinated with all treating providers. That often means cases take on a life of their own, move forward with no coordination, and waste time and money.

That’s why the role of the nurse case manager can be so important in reducing costs associated with hospital stays, surgeries, and a number of chronic illnesses. The nurse case manager ensures that specialty referrals are made promptly, that the patient understands the treating provider’s instructions, and that orders for prescription drugs are followed to enhance recovery. The ultimate goal of the nurse case manager is to assist the patient in returning to optimal health as soon as possible — and that saves money for everyone!

MediReview has a team of registered nurses who are Certified Case Managers. Collectively, we have managed hundreds of thousands of cases over 30 years. There are a number of tools used by our nurse case managers, but perhaps the one that’s most valuable is their knowledge of the healthcare system, how to move someone through it effectively and expeditiously, and what questions to ask.

Frequently individuals faced with illness and hospitalization are frightened and anxious, and they don’t always understand everything the treating provider has to say — or know what questions to ask. Our nurse case managers are perfectly suited by education and temperament to ensure good communication amongst all relevant parties.

Other tools that our nurse case managers might access are:

Centers of Excellence – Nothing saves money like great care, and great care often comes from facilities that have devoted extra effort to understanding and treating a particular disease process. For instance, some facilities specialize in heart care and have better outcomes than those that don’t. It is MediReview’s job to help identify those Centers of Excellence, and when possible, ensure that your patient is treated where the outcomes are the best.

Disease Management – Proactive management of diseases reduces complications and saves money for all concerned. MediReview has specific programs that can help better manage chronic diseases such as diabetes and congestive heart disease.

Patient Accountability and Compliance – Compliance with pharmaceutical treatment plans, communication amongst a variety of treating providers, and appropriate specialty referrals help you get the most out of your healthcare investment by holding the patient and treating provider accountable.

Specialty Medications – Customized pre-certification approval criteria may be implemented for expensive and/or experimental specialty medication requests.

Single Case Agreements – MediReview case coordinators are uniquely trained to identify out-of-network providers/facilities and to negotiate Singe Case Agreements to reduce charges to reasonable levels based on reference-based pricing.

Healthcare Navigation – Our experienced intake specialists are available to assist patients in navigating the complexities of the healthcare system and identifying appropriate providers/facilities for care.

For more information about Group Health services, contact MediReview at (800) 850-0281 or