Case Management

The Mercy Case Management program addresses health management at the individual patient level. Case Managers provide intensive one-on-one care management and coordination for individuals with complex, catastrophic illness or injury.  They collaborate with the patient and family, physicians and the care team to assist in development and implementation of the treatment plan. Services are primarily telephonic, but may include onsite visits as needed. Patients being case managed have access to Registered Nurses for support 24 hours a day, seven days a week.  Our nurse Case Managers are all Registered Nurses, receive certification in case management and adhere to Case Management Society of America (CMSA) Standards.

Goals of Case Management include:

  • Promotion of patient self-reliance through education and lifestyle coaching
  • Coordination of complex medical services across the full continuum of care, reducing fragmentation
  • Reductions of delays and duplication of services
  • Optimization of the physician-directed treatment plan
  • Benefits and resource management, with development of cost-effective alternatives when needed
  • Negotiations of pricing and assistance in procuring service

Specialty services are available for Transplants, Behavioral Health, Oncology, High Risk OB, Geriatrics and Obesity.

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Claims Administration

As your claims administration partner, our job is simple. We will pay members’ health claims:

  • Accurately
  • On time
  • In accordance with your plan and provider contracts

Your members will enjoy the convenience and ease of managing their health care via our secure website. Online services include:

  • Print an ID Card
  • Change eligibility information
  • Search for providers
  • View and print Explanation of Benefit (EOB) forms

Toll-free customer service lines are also available to resolve claim inquiries promptly. Our average turnover time for claims processing is 12 business days.

Mercy is the largest managed care provider in the region with a 35-county service area encompassing 25,000 square miles. Among the top 20 major employers in our region, 60 percent contract with Mercy Managed Care.

Mike Rowland

“Mercy has done an excellent job looking out for our associates. They have a great relationship as far as being an honest, forthright claims administrator who looks out for the best interests of our employees.”

Mike Rowland
Vice President of Human Resources
Bass Pro Shops

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Data Management

If your organization’s health care expenses seem out of control, help is available.

You may not be able to lower rising medical costs single-handedly, but there are things you can do to improve the health of your employees and their dependents while reducing medical expenses.

Program Benefits:

  • Data-driven queries identify health care cost drivers and service utilization
  • Quarterly consults
  • Innovative Report Cards with actionable data
  • Joint-effort action plans, zeroing in on areas of highest impact potential

Mercy Data Management utilizes state-of-the-art information systems to collect, store, track and analyze data. This advanced technology, along with claims analysis techniques, allows us to provide clinically driven report cards identifying where health care dollars are going. Based upon this information, appropriate interventions are recommended, specific to each organization, and results are tracked on a monthly, quarterly, and annual basis.

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Disease Management

Many organizations realize the importance of offering programs to promote employee wellness, but what about those already suffering from chronic disease? In most cases, a few chronically ill members are responsible for a majority of a group’s health care expenses. Supporting these individuals in managing their chronic illness leads to a positive outcome for everyone involved.

Managing chronic illness can be difficult. Mercy Disease Management Program can help your chronically ill employees experience a better quality of life. 

Mercy Disease Management programs have earned accreditation from the National Committee for Quality Assurance (NCQA) for patients with the following complex, chronic conditions:

ncqa logo

The NCQA is an independent, private organization dedicated to measuring the quality of America's health care.

Earning NCQA DM Accreditation is an indication of the quality of Mercy's disease management programs. It reflects our system-wide commitment to providing a high level of care and service to obtain the best outcomes for our patients.

In addition to the accredited programs, we have three newer programs including:

Chronic disease management can greatly improve the quality of life your employees enjoy, while helping to reduce your organization's long-term health care costs.

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Utilization Management & Review

Mercy Utilization Management (UM) provides monitoring and evaluation of patient care and services. The goal is to ensure that patients receive high-quality, cost-effective care at the appropriate time, and in a setting that is most consistent with their needs. Utilization Management Nurses use evidence and knowledge-based criteria to evaluate the medical necessity and appropriateness of health care services.  

Additionally, the UM department provides:

  • Resources and information to providers for optimum management of patient care
  • Precertification for specified procedures or services, such as Home Health Care,    Durable Medical Equipment and Skilled Nursing Facility
  • Screening for potential referrals to Case Management and Disease Management programs
  • Inpatient hospital admission and continued stay review
  • Discharge planning to ensure continuity of patient care from the hospital to the next level of care

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