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Through attentive care, dedicated service, and comprehensive guidance, nursing staff make a tremendous impact on patient outcomes.
As an integral part of Valenz Clinical Engagement, a URAC-accredited solution within the complete Vālenz Health® ecosystem, nurse case managers and utilization review nurses work closely with health plan members to ensure the right care at the right place and time, paving a more cost-effective path to healthy outcomes.
This week marks National Nurses Week in the United States. As such, we are celebrating the vital role nurses play in supporting strong, vigorous, and healthy lives among health plan members — and the superior outcomes they make possible as part of the Valenz full-cycle approach to care.
Utilization and Case Management: The Cornerstones of Valenz Clinical Engagement
In today’s complex healthcare environment, experienced nurses are an invaluable resource for health plan members, helping them to coordinate and manage their personal care journeys for reduced costs and better care outcomes.
Case management is a collaborative process. In coordinating patient care, nurse case managers work closely with physicians, social workers, patients’ families, and other providers, such as home health nurses and physical therapists.
Regardless of the individual patient case, the goals of nurse case managers remain the same: determine the kind of care needed and guide the member through improving their health, minimizing the expenses incurred along the way.
Through the Clinical Engagement solution suite, nurse case managers become the central point of contact for members, serving as their advocate in finding and accessing high-quality, low-cost care.
Utilization management nurses also play a critical role in the process. By determining medical necessity via case review, these nurses proactively ensure alignment with the most appropriate level of care — care that nurse case managers ultimately help patients secure.
Health plan members aren’t the only ones who benefit, however. Self-funded employers, plan sponsors, and other stakeholders who use utilization and case management services to manage healthcare costs and quality experience a reduction in unnecessary and/or preventable emergency room visits, hospitalizations, tests, and other high-dollar claim events.
In short, utilization and case management as part of the Clinical Engagement solution are full-cycle strategies for optimizing the cost, quality, and utilization of healthcare for everyone — a key part of our mission at Valenz.
How Valenz Nursing Staff Support Smarter, Better, Faster Healthcare Outcomes
The level of care and service provided to members through the Clinical Engagement solution is a point of pride among our organization. With the tireless work they put in every day, our nurses directly improve care quality and outcomes among our clients’ health plan members, supporting the strong, vigorous, and healthy lives we are so passionate about here at Valenz.
How do they make it happen?
Through dedication, hard work, and an ongoing commitment to serving patients, wherever they are at in their healthcare journeys.
Patient Education and Support
By providing continuous, evidence-based guidance and education, nurse case managers fulfill a key responsibility in helping patients and families fully comprehend health conditions and treatment options, so they can stay on the path to better long-term outcomes.
“When patients have greater awareness and understanding of the treatment plan — and when they receive support from nurse case managers — we tend to see a much better likelihood of compliance,” said Valenz Nurse Case Manager Jessica Mangum, RN, OCN, CCM.
Nurse case managers also provide guidance to patients for effectively self-managing chronic conditions. This way, patients can take charge of their health and be their own catalysts in making positive lifestyle changes that cause a positive ripple effect over time and support a longer, healthier life.
Reduction in Unnecessary Care Costs
While providing comprehensive care that is appropriate for the patient’s needs, Valenz nurses also strive to minimize out-of-pocket costs.
When our utilization review nurses are notified of a new diagnosis or treatment recommendation, they conduct a clinical review to determine that the criteria are met for medical necessity and to ensure alignment with the most appropriate level of care, according to evidence-based guidelines for that diagnosis. This helps eliminate expenses tied to unnecessary or excessive treatments, a goal further supported by the nurse case managers that patients are referred to once the review process is complete.
“When we can manage the length of stay and promote case management, we can achieve effective cost containment while providing excellent service to the members and the plan,” said Magnum.
In addition, the shift in focus to proactive health management — supporting members in accessing regular medical care before serious illness strikes — enables nurse case managers to help reduce or eliminate the need for costly medications and physician or emergency visits.
That’s a benefit for patients, payers, plans, and providers alike.
Assistance with Navigating the Health System
For many people, the complexities of the healthcare system can feel so overwhelming that they don’t know where to start.
“Some of the biggest challenges patients face in navigating their care is lack of understanding of the healthcare industry,” said Valenz Vice President of Care Management Suzanne Symons, RN, CCM. “The average patient does not grasp how insurance and healthcare work. They often become frustrated and give up, and then they lose trust in anyone in the healthcare field.”
That’s where a nurse case manager comes in: providing guidance and information on what is covered by a patient’s insurance, managing copays, controlling out-of-pocket expenses, and ensuring accessibility to care, among many other issues.
“Patients need an advocate to get them through this journey,” said Symons. “We can research insurance plan documents to give patients the clarity they need; help them understand what benefits they are entitled to; determine whether they need pre-certification before treatment; and assist them in securing all those things.”
Patients with serious diagnoses like cancer may need a wide range of procedures and tests, which can quickly become confusing for a stressed patient. Clinical Engagement provides the extra level of support needed for these members, allowing them to focus on what matters most — the treatment and recovery process.
Support Better Care Outcomes for Plan Members with Vālenz Health®
During National Nurses Week (and every other week of the year), Valenz is honored to count more than 60 skilled nurses as part of our Clinical Engagement, Utilization Management, Surgical and Imaging, and Clinical Bill Review teams. Their work guiding and supporting health plan members is invaluable to our mission of engaging early and often for smarter, better, faster healthcare for all.
As part of our Clinical Engagement solution, these clinicians manage and influence member care to control costs, improve care outcomes, and create a positive healthcare experience for the members who need it most through three key features:
- Utilization Management, which proactively identifies high-risk populations to control inappropriate spend before it happens
- Case Management, which manages the most expensive of healthcare conditions and claims during member treatment to deliver an above-industry-average engagement rate of 17%
- Disease Management, which empowers members with chronic conditions to self-manage their healthcare journeys for better outcomes over time
Together, these three features — and the nurse case managers who work as part of them — help to optimize health outcomes throughout the entire care journey, yielding an average return on investment of 8:1 for our clients.
Learn more about Clinical Engagement and how it can support your plan members for strong, vigorous, and healthy lives by contacting a Valenz team member today.
