Clinical Services

The Health Plan Clinical Services Department delivers a clinically-driven, technology-enhanced, customer-focused platform that manages and improves the health and well-being of our members.

Utilization Management

We want our members to get high-quality, cost-effective treatments. Our team of experienced doctors and registered nurses provide oversight of many health care services we provide to members. Utilization management ensures that our members receive quality, effective treatments and seeks to avoid any unnecessary hospital stays and procedures. Led by our in-house team of medical directors, our nurses perform a thorough review of a member’s clinical history and interact with the whole health care team. By understanding a member’s needs and circumstances, our nurses can better advocate for improved quality of care, prevent patient complications during a hospital stay, seek to get members home sooner when appropriate, and provide continuity of care.

Wellness Programs

The Health Plan recognizes that preventive services are the key to wellness. Our benefits and programs encourage people to stay healthy by seeking routine preventive care with their primary care physician, as well as medical treatment at the onset of illness. We provide a broad spectrum of wellness services focusing on promoting healthy lifestyles and enhancing the quality of life for our members and their families.

The Health Plan has a team of Member Advocates who welcome new members and assist them in completing health assessments, coordinating benefits, providing referrals to necessary health services and facilitating access to or arranging community resources. Additionally, our registered nurses can provide education and support to help keep you healthy. 

Care Management

For members who have experienced a life-altering injury or medical condition, The Health Plan nurse case managers are here to help. Our nurses coordinate care and offer support throughout all phases of our members' journey to better health. Our registered nurse case managers work as a team with doctors and other care providers to get members back to health by coordinating appointments and ensuring they receive top-quality care.

Behavioral Health

Members who are diagnosed with a behavioral health condition have access to our in-house Behavioral Health Services team. Our team of certified behavioral health professionals help members gain independence and learn to live well with their condition. The Health Plan provides service to inpatient and outpatient behavioral health services, including substance use disorder. We have an experienced team who can offer assistance with many behavioral health conditions, including:

  • ADHD
  • Anxiety
  • Bipolar disorder
  • Major depressive disorder
  • Psychosis
  • Schizophrenia
  • Substance use disorder

Some services may require prior authorization. Your PCP or our Member Services team can help you get these services from behavioral health providers. Call us at 1.877.221.9295, Monday-Friday from 8am-5pm. If it is an emergency, call 911 immediately.

Disease Management

Members living with diabetes, coronary artery disease (CAD) congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), or are experiencing a high-risk pregnancy, don’t have to go through it alone. The Health Plan offers programs consisting of educational mailings, telephone calls, and counseling to help better-understand these conditions.

Our in-house care team provides education on proper preventive care and testing to help monitor conditions. Our registered nurses are available to answer questions about these conditions, medications, or lifestyle changes that can help lead to improved quality of life. 

Healthcare Analytics

The Health Plan incorporates health care analytics into all aspects of the care continuum to help members receive better care, sooner and at a lower cost. We use data to enhance our team-centered approach to ensure our members receive the care and resources they need.