The medical management division of Western Medical Management is comprised of a physician-medical director, a team of highly skilled nurses (RNs and LVNs), and experienced case-management personnel; all of whom are dedicated to ensuring that Arta members understand their covered health care benefits and that they have timely access to medically-necessary health care services. This team of integrated health care professionals performs case and utilization management functions for Arta members as follows:
Case Management
o Conduct a comprehensive assessment of a member’s health care needs and work closely with the member, the member’s primary care and specialist physicians, community agencies and other health care providers in developing a plan of care designed to fulfill the member's health care needs and goals
o Work closely with the Member and the health care team to explain a member’s covered health care benefits and facilitate communication and collaboration among providers to ensure the continuity of the member’s care, and to minimize the fragmentation of care and any barriers to accessing care
o Educate member on his or her health care conditions, including the procedures and medications indicated for specific diseases; refer member to community agencies and resources when necessary to improve access to care
o Advocate for the member and encourage appropriate use of health care services, and make reasonable efforts to facilitate positive outcomes until member’s health care goals are met
Utilization Management Functions
o Review and approve requests for services based on a member’s health plan and covered benefits
o Coordinate and communicate with both internal and external health care teams, including primary care and specialist physicians, hospitals, and ancillary service providers to ensure that members receive services at the appropriate level of care
o Facilitate member referrals to health care providers for appropriate level of care based on medical necessity
o Identify and recommend high-quality and cost-effective alternatives of care whenever possible