High-quality Services Support to Health Care Entities at its Best

Case Management

What is Case Management?

Case Management (CM) entails the management of members who are enrolled through a plan partner relationship (e.g., LA Care, CalOptima, Health Net, etc.) that require assistance with their care coordination needs or require review of utilization controls. 


The assistance provided includes moving members between care settings, developing a patient-centered assessment to determine their medical, social, and behavioral health needs.  In turn, developing a personalized care plan geared towards short- and long-term goals. 


The care plan is developed by a nurse or social worker utilizing the member’s available clinical and verbalized information that is tracked and monitored until all goals and/or objectives are met.

What programs are under Case Management?

Case Management is tiered into different categories. 


Under each tier, there are programs assigned to them. 


Programs are based on regulatory requirements or identified population needs from utilization activity (e.g., major organ transplant, high risk OB, recent catastrophic event, multiple admissions or ER visits). 






Delegation of
Case Management

Staffing resources and case load ratios are based on the activities delegated by the health plan partners. Case Management is not delegated for all plans or lines of business. The following are the plans and lines of business we are delegated to perform case management activities: 






Brand New Day (SNP)

Anthem Blue Cross (MCR, MCL, Commercial)

Cal Optima (All LOB’s)

Blue shield

HealthNet (CMC, SNP)

Blue Shield Promise (CMC, MCL, SPD)


Brand New Day (MA & SNP)

United (MA, Commercial)

Cal Optima (All LOB’s)

WellCare (MA, SNP)

Central Health Plan (SNP)


HealthNet (CMC, SNP, MCL, MCR, Commercial)


LA Care (CMC, MCL, Commercial)


Molina (CMC, MCL, Commercial)




United Healthcare (MA, Commercial)


WellCare (MA, SNP)


Case Management Variation by Line of Business

The Case Management care coordination activities may vary based on the line of business. This is because each line of business may have specific program requirements/standards. 






How are cases identified?

Program inclusion criteria is identified through the following data sources:


How do you refer to Case Management?

A member may self-refer to Case Management by calling Member Services, or working directly with their Primary Care Provider to submit a referral form. 


A Case Management referral form must be completed by the provider and include the following:








How is care conducted?

The Case Management team consists of nurses, coordinators, and social workers. Each team member plays a key role in the care delivery process: 



Occasionally, the member may be consistently unable to reach, or may decline to participate in the CM program after enrollment. If this happens, the case is brought to the Interdisciplinary Care Team (ICT) and the Medical Director will review, make recommendations, and authorize case closure. 

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