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Gulf Coast Medical Management


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What is Gulf Coast Medical Management?

The Gulf Coast Medical Management department is a division of SMHCS and was created to assist SMHCS employees in managing their healthcare needs through acute care, chronic disease and pharmacy case management.  The department consists of two RN case managers, a Chronic Disease Case Manager and a Pharmacy Case Manager.  These case managers are under the direction of the SMHCS health plans’ Medical Director.

The RN Case Managers use Milliman’s Evidenced-based Care Guidelines® which cover the spectrum of care for acute conditions.  Using these guidelines, the RN Case Managers work with SMHCS and other healthcare providers (both physicians and facilities) to ensure that members receive quality and proactive care while controlling cost to both employees and SMHCS.

The Chronic Disease Case Manager works with employees who have been diagnosed with chronic diseases, such as diabetes, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and others.  In addition to utilizing Milliman’s Evidenced-based Care Guidelines®, the Chronic Disease Case Manager also uses predictive modeling tools (MDI Healthcare Solutions Analytics Suite®) to identify the most severe conditions.  This early detection helps the Chronic Disease Case Manager to quickly respond to those members with higher risk for potentially serious healthcare issues and to facilitate a working relationship between the member and their healthcare team.

The Pharmacy Case Manager is available to work with SMHCS employees and their dependents to recommend generic alternatives and to help bring down the costs of prescription drugs.  Working with the Pharmacy Benefit Manager (Navitus®) and physician providers, the Pharmacy Case Manager will review and discuss current prescriptions with the member and make suggestions for alternatives that decrease costs while maintaining prescribed regimens.

Listed below are some of the activities in which the Gulf Coast Medical Management Case Managers assist SMHCS employees and their dependents:

  • Authorizations for surgical and diagnostic procedures
  • Assist with referrals to out-of-network facilities and physician providers when medically necessary
  • Coordinate care between primary care physicians, specialists, and other providers
  • Develop preventive care programs for those with chronic disease conditions
  • Review current drug formularies for changes in generic medications and keep benefit-covered prescription listings up to date
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