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Collaborative Case Management Issue 97

Publication Date: 7/21/2025


Abstract
The health care sector faces mounting pressures due to a convergence of workforce shortages and increasing administrative burdens, particularly in Case Management and insurance denial processes. This article examines two critical, interrelated domains: the development of effective staffing models for Case Management programs and the optimization of medical necessity appeal strategies in response to payer denials. The first section examines methodologies for developing evidence-based staffing models that consider departmental objectives, patient population complexity, and caseload variability. Emphasis is placed on aligning staffing strategies with the Quadruple Aim, with practical guidance on determining appropriate staff-to-patient ratios and recruiting high-performing Case Managers in a competitive labor market. The second section presents a case analysis of Stanford Health Care’s Denials Management framework. The discussion highlights the integration of peer-to-peer (P2P) review coordination, Epic-based appeal documentation, and evidence-based clinical justifications to challenge payer denials. The study further explores the impact of tracking denial trends and leveraging data in payer-provider Joint Operations Committee meetings to improve appeal outcomes and address systemic barriers. Together, these strategies represent a comprehensive approach to enhancing Case Management operations and financial recovery efforts. Findings support the need for ongoing innovation in workforce planning and denial management to maintain both care quality and institutional sustainability in today’s evolving health care environment.


Learning Objectives

Two Steps to Hiring Great Health Plan Case Managers
1. Describe methodologies for developing effective staffing models in Case Management
2. Identify key factors that influence the efficiency and accuracy of caseload estimations
3. Apply best practices for recruiting and selecting high-caliber Case Managers


Navigating the Maze: A Comprehensive Guide to Medical Necessity Appeals
1. Leverage Peer-to-Peer (P2P) Efforts:Describe the role of peer-to-peer reviews in the appeal process, including collaboration with hospital treating physicians and third-party physician advisors; Demonstrate how tracking P2P requests and outcomes within Epic can improve appeal success rates and payer accountability
2. Utilize Technology to Optimize Appeals: Introduce an Epic-based appeal letter template designed to streamline appeal writing and ensure inclusion of essential clinical details; Discuss best practices for documenting and analyzing P2P interactions to strengthen future appeals and improve efficiency
3. Enhance the Effectiveness of Appeal Letters:Strengthen medical necessity appeal letters by incorporating robust, evidence-based justifications that directly address payer denial rationales; Employ strategies to challenge payer denials by demanding clear clinical justification from the denying medical director
4. Identify and Address Trends in Denials: Recognize common denial trends and their impact on patient care and hospital revenue; Develop strategies to present denial data and trends in Joint Operations Committee meetings with payers to address administrative barriers, such as unclear timelines for P2P or reconsideration requests


Speakers:
Lynn Bree, MHA, CMAC

Lynn Bree holds a Master of Health Administration and has built a distinguished career in managed care and health care services. She most recently served as Vice President of Health Care Services for Molina Healthcare of Wisconsin and Illinois, where she oversaw care coordination, utilization management, and quality improvement efforts. Now retired, she continues to lend her expertise as a member of the Health Plan Compass advisory committee for the American Case Management Association.

Colette Seaberry, MSN, RN, ACM; Mary Rose Ready, MSN, RN, ACM, CCM; Rozalyn Romo, MSN, RN; Gwen Baum, MSN, RN, ACM, CCM

Colette Seaberry is a Denials and Appeals RN at Stanford Health Care, where she plays a key role in managing medical necessity denials and navigating complex appeals. She brings a strong background in clinical nursing and case management, with a focus on improving outcomes through strategic payer collaboration.

Mary Rose Ready serves as a Denials and Appeals RN at Stanford Health Care. With dual certifications in case management and a master’s degree in nursing, she applies her expertise to strengthen appeal strategies and advocate for timely, appropriate patient care across the continuum.

Rozalyn Romo is a Denials and Appeals RN at Stanford Health Care. She leverages her advanced clinical training and nursing experience to support appeals processes, ensuring alignment with evidence-based practices and payer policy requirements.

Gwen Baum is a Denials and Appeals RN at Stanford Health Care with extensive experience in case management and utilization review. Her work focuses on optimizing appeal outcomes, addressing payer denials, and advancing care quality through data-informed strategies.

Keywords: staffing models, workforce planning, medical necessity, insurance denials, denials management, appeals process, peer-to-peer review (p2p), clinical justification, quadruple aim, utilization management, hospital operations, payor-provider collaboration, joint operations committee, evidence-based practice, health care workforce, care coordination, health system sustainability

Collaborative Case Management Issue 97

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