Medical case management is the continuous assessment, monitoring, planning, and coordination of patient care. A collaborative process, it includes directing patients to the right providers, post-discharge planning, and assisting with transfers, among other responsibilities.

At GMMI, our URAC accredited program includes 20+ medical case managers, all of whom are registered nurses, and four doctors with extensive experience in trauma level 1 situations. Between them, our nurses have specialized expertise in emergency nursing, medical-surgical nursing, psychiatry and rehabilitation, cardiac nursing, labor and delivery, hospice, orthopedics, and other areas. Ensuring that patients are getting the necessary, most appropriate, most cost-effective, and highest quality of care, our medical case managers are the key liaisons between hospitals and our client’s members.

When performing medical case management and utilization reviews, our medical team leverages clinical, evidence-based medicine to determine appropriate levels of care. These assessments are guided by the industry’s most reputable criteria. The goal of evidence-based medicine is to ensure that healthcare-related decisions are based on the most current, proven, and reliable scientific evidence.

GMMI medical trainer & case auditor and certified case manager, Corie Pinero, RN, gives us a glimpse into the world of medical case management. Providing medical assistance and oversight, our case managers ensure that patients are receiving the safest and most effective care. “For members that have chronic or complex conditions, we provide guidance, education, and support. Medical case management helps members improve their quality of life and it also helps them to have a person that they can call or write to if they have questions or concerns,” says Pinero.

Having a broad medical background is essential to successful medical case management. According to Pinero, “You also need to have good listening skills and the ability to think outside the box.” While case management processes are the same around the globe, managing cases outside the U.S. has its challenges. “Community resources for members can be limited overseas. You also have to navigate benefit limitations and differences in medical care. Time differences can be a challenge as well,” says Pinero.

Pinero finds fulfillment and purpose caring for members with chronic and complex conditions, despite working in a setting in which physically interacting with the patient is not possible. “Hearing and reading from our members that their health has improved, that you made a positive impact in someone else’s life, and just knowing that you are relieving some of the burden for members and their caregivers, is a reward.”

At GMMI, the efficient use of case management criteria strengthens the claims adjudication process and ultimately saves money for our clients. “We provide detailed reviews of medical records and intervene when needed, ensuring the best outcome for our clients and their members,” says Pinero. By helping providers supply the correct treatment and ensuring that patients are receiving the most appropriate care, effective medical case management reduces costs for insurers and for members. Ultimately, the program is fundamental to the business and empowers the GMMI five rights of care: ensuring the delivery of the right care, at the right time, with the right provider, for the right price and the right outcome.