Interpreting Milliman Care Guidelines as well as collaborating with our Medical Director to review all dynamically changing services (i.e. genetic testing) we use evidence-based treatment guidelines to enhance the quality and effectiveness of patient care while eliminating excessive treatment and expense.

Our Care Managers manage utilization of healthcare services in alignment with employer plan benefit and medical necessity through medical record/clinical documentation review. We manage health utilization at targeted times in the member’s care continuum looking across services, procedures, and facilities. We certify member’s outpatient services, specialty medications and durable medical equipment, preadmission and concurrently during an inpatient stay, acute or post-acute.

Our in-house teams manage all denials facilitating 1st and 2nd level review of appeals working ensuring independent, unbiased determination of medical necessity beginning with an initial clinical review, then moving to a peer clinical review if needed via an IRO. This maintain efficiency of care and allows HDP to continue to advise employers on effectiveness and appropriateness of plan benefits; looking at aligning incentives and engagement activities to drive engagement and lower healthcare costs.

RNs with a focus on assisting individuals managing chronic conditions through personalized goal setting and collaboration among the care team to better manage their health. Our nurses are hands-on working to remove barriers to chronic condition compliance. We have the necessary knowledge and experience bringing other vendors and providers/specialists to the table to meet the individual member’s needs.

We have pathways for all Ambulatory Sensitive Conditions and more: COPD, CHF, Diabetes, Asthma, Heart Disease, and Musculoskeletal Low Back Disorders.

Registered nurses with a specialty in perinatal care provide state-of-the-art education and counseling to empower women to be active participants in their own care. This program is an adjunct to regular obstetric care and coordinated with a physician or midwife, or even a population health feature such as an Accountable Care Organization or Clinically Integrated Network.

This program has demonstrated increases in term-births (36 weeks plus), reduces elective cesarean births and prevents low birthweight driving a healthy population with “big, healthy, happy babies.” Our clients see these services provide a greater than 7:1 return on investment.

Working onsite with the client, RNs utilize care coordination skills in combination with clinical and benefit knowledge to function as a member/patient advocate promoting patient engagement in applicable programs and services while supporting internal teams and external partners in optimizing those services and programs.

This role works in collaboration with other members of the Care Management team providing a high-touch experience for the member and the client managing the complex nexus between members, provider and employer benefits.