Care Coordinators Clause Samples
The Care Coordinators clause designates specific individuals or roles responsible for managing and overseeing the coordination of care services within an agreement. Typically, this clause outlines the duties of the care coordinators, such as serving as the main point of contact between parties, facilitating communication, and ensuring that care plans are implemented effectively. By clearly assigning these responsibilities, the clause helps streamline service delivery, prevent miscommunication, and ensure accountability in the management of care.
Care Coordinators. Each Enrollee identified as requiring Care Management, and any other Enrollee who agrees or wishes to receive Care Management, will be assigned a Care Coordinator.
Care Coordinators. Each Enrollee who receives Care Management will be assigned a Care Coordinator. Contractor must provide Enrollee information on how to contact the Enrollee’s designated person or entity primarily responsible for coordinating services.
Care Coordinators. Each Enrollee identified as requiring Care Management Services and those who agree will be assigned a Care Coordinator. Care Coordinators assigned to Enrollees with varying risk levels shall have their overall caseload weighted and a blended overall caseload limit set, taking into account the location of the Enrollee. Contractor will provide the Department with its methodology for assigning Enrollees with varying risk levels for Prior Approval. The Department may review existing caseloads at any time and require a change in methodology or an Enrollee’s assignment to a caseload. Caseloads of Care Coordinators shall not exceed the following standards:
Care Coordinators. The Plan shall utilize licensed personnel in medical professions to review requests for Prior Authorization and perform the duties of Care Coordinators. Such Care Coordinators shall have authority to perform Utilization Review per established scientific, evidence-based clinical criteria for the purpose of making a determination as to the Medical Necessity for services under the terms and provisions of the Member's Benefit Agreement. Utilization Review Criteria shall be based on currently established and recognized medical and professional expertise, studies, treatises and literature, and current cumulative information, data and studies on health care services available and provided within the local community.
Care Coordinators i. Manage care navigation for demonstration enrollees in patient centered medical homes, emergency department, and during transition from inpatient care
ii. Assist patients to improve compliance with care
iii. Extract and assess data to maintain disease management registries for demonstration enrollees
iv. The functions performed by the care coordinators are similar to what an Administrative Services Organization (ASO) would do to operate the demonstration. For example, an ASO staff person would manage a demonstration enrollee’s navigation of care options and compliance with directives indicated by health care professionals, and extract and assessing data to maintain disease management registries. No portion of the care coordinators’ time will be the provision of direct services to beneficiaries. The activities described above will not be claimed as service costs. All activities will be claimed as administrative costs. These services are directly related to provision of waiver services and are necessary for the proper and efficient administration of the waiver. The state and MetroHealth will ensure that there is no duplication of claiming because care coordination is not offered as a direct service under the demonstration; the only care coordination offered under the demonstration is administrative. • Consulting Services – Invoices or check requests will be properly approved along with documentation of the relationship to the demonstration.
(1) Examples of consulting services engaged by MetroHealth are noted below along with examples of their responsibilities: