Medical Management

Medical Management

Managing Quality Care for Optimal, Cost-Effective Outcomes

Our Utilization Management services ensure our clients have access to effective and efficient medical services. Our team and systems evaluate the medical necessity and determinants of medical services provided by participating physicians, hospitals, and other ancillary providers.

Our solutions coordinate with capacity and performance management to ensure the costs for services are not due to poor performance or resource abuse.

We know improving member health and keeping members healthy is the key to lowering costs. With our integrated approach and commitment to achieving high member engagement, we help clients stay ahead of the ever-rising costs of healthcare.

Our Utilization Management Services Include:

  • Prior Authorization Entry
  • Evaluation Appropriateness of Medical Service(s)
  • Prospective and Concurrent Claim Reviews
  • Retrospective Reviews
  • Disease Management
  • Drug Management
  • Authorization Mailings
    1. Authorization Determination Mailings
    2. Provider and Member Notifications
  • Case Management
    1. Initial assessment of members’ health status, including condition-specific issues
    2. Evaluation of available benefits
    3. Development of an individualized management plan
    4. Smart goals with interventions to ensure the member is working towards the goal(s)
    5. Identification of barriers to meeting goals or complying with the plan
    6. Development of a schedule for follow-up and communication with members
    7. A process to assess progress against case management plans for members
  • Discharge Planning
    1. Patient Centered Medical Home (PCMH)
    2. Level 1-3-Tiered Care Plans Matching Disease Severity and Member Needs
    3. Chronic Condition Management through integrated benefits, network, and care management activities
    4. Barrier reduction, such as difficulties with transportation, finances, lack of support system, environmental issues, dual diagnoses, and language barriers
    5. Support of members through care transitions