Medical Management

JMA's experienced clinicians conduct pre-authorization services according to your medical criteria hierarchy.
Our team works with your providers to assure an effective cost control process is consistent and timely.
UM Intake for both Inpatient and Outpatient
UM Outpatient Clinical Reviews/Prior Authorization
Discharge PlanningInpatient Concurrent ReviewHome Health ReviewEmergency Department Care Coordination

Claims

Claims Operations Department is responsible for timely routing and proper adjudication of all claims to meet regulatory timeliness and payment guidelines established for each line of business. Business rules and standards for effective claims processing are continually established and approved by each of our clients. 

Inpatient Case Management

JMA's Inpatient Case Management Team follows your patient/member through all levels of an inpatient admission starting from triage with transfer to capitated facility (depending on bed availability) to acute care admission.                                                                       Initial Er Triage call                                                            Transfers to capitated facility from out of network facility (depending on bed availability)                                                                Hospital admission initial and concurrent reviews, working with your organization's medical directors to determine continued medical necessity per established guidelines                                                                                Monitor admission for correct Level of Care(LOC)                                                                      Monitor Discharge Plan including all medical necessary post acute treatment authorizations are inplace with contracted vendors                                                          Tertiary Transfer requests for Higher level of care (HLOC)                                                      Short term rehabilitation admissions (SNF/Acute)               

Case Management-Outpatient

JMA's Case Management department consists of RNs, LVNs, social workers and other allied health workers. The dedicated case management staff are assigned to members with chronic conditions or other needs that require one or more of the following services:

Facilitating conference calls between the member, the physician and the case manager as needed to clarify treatment plans, medication regimens or other urgent issues

Assessing the member's daily living activities and cognitive, behavioral and social support

Connecting members and their families with professionals who can help them address medical, legal, housing, insurance and financial issues facing older adults

Assisting members in obtaining home health and durable medical equipment

Monitoring medication adherence

Assessing the member's risk for falls and providing all-prevention education

Helping caregivers access support and respite care

Arranging access to transportation

Referring members to meal-delivery programs and advance directive preparation services

All Medi-Cal newly enrolled SPD members and D-SNP EAE members will have a Health Risk Assessment performed within 4 days to identify the need for expedited services, eligibility in complex case management, risk factors, and health information.

Chronic conditions addressed through our case management program include but are not limited to chronic obstructive pulmonary disease, congestive heart failure, coronary artery disease, hypertension, HIV/AIDS, asthma, and diabetes.

Delegation Oversight 

Delegation Oversight plays a pivotal role in safeguarding the integrity and quality of healthcare services. This ensures that all partner organizations strictly comply with the necessary regulations and contractual agreements. Through the execution of comprehensive audits and meticulous evaluations, the auditor verifies that every operation aligns with your health organization's commitment to excellence in quality and efficiency.

JMA will conduct in-depth and systematic audits of delegated entities, ensuring they adhere to all relevant regulations and standards, such as CMS guidelines, state laws, and your health organization's policies. This includes reviewing and evaluating administrative procedures, healthcare services, and data handling practices.

Design and implement comprehensive audit strategies and plans, including defining scope, objectives, and timelines. This involves identifying key areas of focus based on risk assessments and regulatory priorities.

Analyze a wide range of data and information gathered during audits. Interpret complex datasets to identify trends, irregularities, and areas of non-compliance. Prepare detailed audit reports, presenting findings clearly, concisely, and actionable for stakeholders at various levels.

Oversee the implementation of corrective action plans in response to audit findings. Monitor the progress and effectiveness of these plans, ensuring that they adequately address identified issues and lead to sustained improvements.

Regularly review and suggest improvements to your health organization's policies and procedures related to delegation oversight. Ensure that these policies effectively manage risks and align with current industry best practices.

Conduct follow-up audits to assess the effectiveness of corrective actions and continuous compliance.

Maintain a high standard of quality in all audit activities. Ensure that audit processes are thorough, unbiased, and adhere to professional auditing standards.

Perform additional responsibilities as assigned to support the organization's evolving needs.

Quality Management

Opportunities for improvement and best practices are continuously pursued. Formal evaluations of your organization's Quality Management program is continuously performed and documented annually. The Program itself focused on member-centric care and patient-provider relationships while evaluating data-driven decision making throughout the organization.

There are specific activities linked to a QM program which include:

Provider accessibility and availability,

Provider and member satisfaction,

Grievance resolution,

Department call center management,

Improvement in HCC scores resulting in higher RAF scores; and

Population management (detailed below).

Population health, including HEDIS® and STARs measure improvement and is the cornerstone of the Quality Management program. Our quality specialists boost HEDIS® scores, STARs rating and population health initiatives with data quality solutions and initiatives that standardize and extract value from data submitted by network providers and health plans.