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Clinical Care Management

A claim is never about a transaction. It's about care.

No one plans to get hurt at work, but when it happens, it’s good to know you have a claim management partner who looks out for your best interests and the interests of that injured person. You need a partner who focuses on the care of the person and not just on processing the next transaction.

That partner is Optum.

Optum Clinical Care Management uses evidence-based, guideline directed and industry best practices in our clinical programs, services, and interventions to provide effective care and to help ensure an injured person’s safety throughout the claim. 

Our Clinical Care Management solutions fall into five categories:

Identify potential inappropriate treatment or risk factors.

Inform claims examiners of emerging risk within their claim and the recommended actions to mitigate the risk.

Provide a clinician’s deep-dive analysis of treatment using industry guidelines and evidenced-based best-practices to identify appropriate changes in therapy.

Intervene on the client’s behalf directly with physicians or providers, designed to address the specific issues with each individual claim to drive appropriate change.

Provide follow up to interventions to ensure compliance by both the injured person and the provider to help drive optimal outcomes for the claim.

Intervening on high-risk claims leads to improved care and outcomes for the injured person.

Lots of claim attributes and treatments can lead to the clinical concerns and red flags ‒ including the use of multiple opioids, the use of compounded medications, drug-to-drug interactions and more. All of these can raise concerns for the care and safety of the injured person.

This is when Optum Clinical Care Management can make a difference.

Early in the injury lifecycle, we use analytics and insight to identify the claims that may be at increased risk for delayed recovery, sub-optimal treatments, or potential misuse of medication treatments. With the claims identified, we can help to intervene in the injured person’s treatment and educate on options for a better outcome for that injured person.

Medication Review
Comprehensive review of medication history and medical records

Peer-to-Peer Outreach Review
Consult with specialty-matched peer reviewer to drive changes in therapy

Clinical Care Management
Evaluate treatment options for persons at risk of chronic opioid use

Drug Testing and Monitoring
Monitoring program for claims with an inconsistent test result.

Through Optum Clinical Care Management, including the program options listed above, we can help get a claim back on track and ensure the injured person is getting the right care, at the right time, for the right duration and at the most appropriate cost.  

Expertise and insight in our clinical team leads to programs designed to deliver more appropriate care and better outcomes for the injured person.

Without the right team and experience in place, issues may be overlooked, interventions might be missed, care may not be as effective and a claim management program may not be as successful as it can be.

This is why the Optum Clinical Care Management team makes a difference.

With over 45 years of workers’ compensation and auto no-fault experience and the largest staff of specialized and dedicated clinicians in the industry;  the Optum clinical team sets our program apart from the competition.

Our years of experience and expert insight is used to analyze data and recommend programs and interventions that will benefit you and your injured persons. The Optum team is focused and driven to provide the programs and insights surrounding the care of your injured persons. With Optum, your claims can benefit from the following: 

Pharmacotherapy & Therapeutics Committee
Develops formularies and consults on industry issues
Clinical Liaisons
Strategic consultants providing best-in-class utilization
management at a claimant, jurisdiction and client level
Analytics and Informatics Team 
The industry’s largest informatics group delivers cutting
edge predictive analytics and reporting capabilities
Account Management Team
Dedicated team trained on your specific program
to set goals, resolve issues and report on outcomes

For more information on Optum Clinical Care Management, call us at 1‑888‑Optum4U or
email us at

Meet Carlos

Carlos* is a 40-year-old construction worker who sustained a low-back injury and a fracture to the left leg. Following surgery, he was discharged with prescription medications for pain, muscle spasms, constipation, depression and insomnia.

His medication regimen for the types and duration of his injury triggered our clinical alert and clinical letter programs. These programs recommended lower cost and generic medications and changes to his prescription therapy all while maintaining safe and effective care.

Due to the number and types of his medications, Drug Testing and Monitoring was recommended. His testing detected  inconsistencies indicating a lack of compliance and a Peer-to-Peer Outreach Review was recommended and subsequently completed. This program lead to a discussion between the clinicians on ways to wean Carlos from his opioid prescription and while still controlling his pain.

Both interventions were successful with a decrease in his dosages of the opioids and acetaminophen and structured drug testing resulted in improving his level of medication compliance.

*Name and image changed to protect injured person’s identity.

To request more info about our Clinical Care Management solutions or to ask a question fill out the form. 

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