Professional Medical Management Services

Patients with major medical diagnoses often struggle to understand complex care coordination, managing multiple care providers, and knowing what to do next. Patients can take better control of their care and the associated costs when they collaborate with the Zelis medical management team to enrich their healthcare experience.

Participating Zelis Open Access Pricing medical management members with high-cost and specialty cases are connected to an experienced Registered Nurse Certified Case Manager who will help review plan benefits, track results, coordinate care, and advocate for them throughout their treatment journey.

Dive Deeper

No patient should have to face the healthcare system alone.

Our URAC-accredited utilization management program provides pre-certification and concurrent review requests for medical services. By utilizing evidence-based standard of care guidelines, services are ensured to be clinically appropriate, administered by proven methods, provided by appropriate healthcare providers, and delivered in the appropriate clinical setting.  

We deliver: 

  • Medical necessity reviews for initial precertification, continuation of care, and retrospective requests.
  • Experienced nurses continually monitor cases to ensure quality and appropriateness of care.
  • Facilitation of appropriate medical care while maximizing opportunities for cost savings.
  • Identification of alternative care options when appropriate to maximize health benefits.
  • Physician reviews with like-specialty peer reviewers for determination of medical necessity, experimental/investigational, plan exclusions, and appeals.
  • Dedicated board-certified medical directors.
  • Comprehensive state utilization review agent licensure and regulatory compliance.
  • Automated precertification reporting customized to meet client requirements  

Our URAC-accredited case management program delivers care coordination to members with the highest needs who have chronic, complex, or catastrophic conditions and/or treatment needs including oncology, end stage renal, organ transplantation, clinical trial, gene therapy, hemophilia, autoimmune, high-risk maternity, birth anomaly, and other rare and complex medical conditions. Case management RN clinical experts support members in achieving optimal clinical outcomes along the continuum of care utilizing evidence-based national standards. 

We achieve program outcomes by: 

  • Providing dedicated Registered Nurse Certified Case Managers with advanced clinical experience, knowledge, and credentials and certifications including Certified Case Manager (CCM), Oncology Certified Nurse (OCN) and Advanced Achievement in Transplant Management (AATMC).
  • Performing medical necessity reviews for assigned members in case management to provide comprehensive care coordination.
  • Coordinating with various transplant networks to implement clinically and financially appropriate transplant contracts.
  • Supporting members to deal with the short- and long-term impact of cancer diagnoses 
  • Completing a comprehensive assessment of the member’s conditions, identifying barriers to care, and developing a comprehensive care plan which prioritizes goals.
  • Offering intensive care coordination including member education, guidance on self-management, coordination with treating providers, assistance with access to community resources, and ongoing care planning.
  • Facilitating outcomes designed to help members regain optimum health and/or improved functional capability in the appropriate clinical setting and in a cost-effective manner.

Disease management is integrated within our URAC-accredited case management program to deliver chronic condition management to members with combined chronic condition diagnosis including asthma, Chronic Obstructive Pulmonary Disease, diabetes, heart failure, coronary artery disease or hypertension. 

We impact care by: 

  • Promoting a one-on-one relationship with a dedicated Registered Nurse with clinical expertise in patient education.
  • Completing telephone assessments to determine member needs and requirements to develop and implement a comprehensive plan of care.
  • Identifying risk with implementation of appropriate interventions leading to optimizing compliance through prevention and proactive interventions based on evidence-based guidelines.
  • Delivering clinical expertise to collaborate with members and treating providers to develop a strategic and customized plan encouraging member engagement and optimizing outcomes.
  • Utilizing motivational interviewing to identify member’s confidence, readiness to change, and ability to self-manage their condition.
  • Delivering self-management by facilitation of compliance with current disease-specific evidence based clinical guidelines to impact health and measure improvements.
For New Clients

Transition of Care Forms

The medical management clinical team aims to provide a seamless transition to the new benefits plan for members who are who are receiving medical treatments that require precertification by the medical benefit plan and to address any concerns regarding potential disruption of recurring medical care. To ensure a seamless transition, members and clients should complete these forms.

Access Forms Library

URAC Accredited

URAC is the independent leader in promoting healthcare quality through accreditation, certification, and measurement. By achieving this status, our organization* has demonstrated a comprehensive commitment to quality care, improved processes, and better patient outcomes.

The URAC accreditation process demonstrates a commitment to quality services and serves as a framework to improve business processes through benchmarking organizations against nationally recognized standards.

URAC Accredited

Health Utilization Management

URAC’s accreditation program assures the clinical and operational soundness of the UM process by evaluating it against nationally recognized standards.

URAC Accredited

Case Management

Case Management Accreditation by URAC validates excellence in care coordination, patient engagement and advocacy, service access and transitions of care.

*Innovative Medical Risk Management, Inc. d/b/a CareValent d/b/a Payer Compass, a wholly owned subsidiary of Zelis Healthcare, LLC, provides medical management services as a URAC accredited organization.

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