Utilization Management

Utilization Management means the planning, organizing, directing, and controlling of healthcare services to assure cost effective, high quality care, while contributing to the overall goal of patient wellness. Healthcare utilization and quality of services are monitored by a formal quality assurance program.

The utilization management process evaluates the appropriateness of medical care to clinical criteria. Effective utilization management will lower costs and increase the quality of care as unnecessary medical treatment is eliminated. It also maintains quality of care by assuring that services provided are of suitable duration, frequency, and level of care to promote an optimal health outcome.

A professional staff of Registered Nurses work with a Medical Director, a licensed physician, to coordinate the following activities of utilization management:

Precertification --An assessment of the physician's treatment plan and/or the proposed schedule of procedures prior to a patient receiving services. Precertification may be performed for both inpatient and outpatient services.

Inpatient Case Management --A coordinated team approach to the management of inpatient care. This process evaluates and coordinates length of stay and discharge planning.

Large Medical Case Management --The goal is to promote effective utilization of healthcare services while ensuring optimal healthcare outcomes for the patients and their families. For certain patients meeting select criteria, utilization management will provide synchrony with covered benefits of a group health plan and negotiation of discounts from healthcare providers and vendors.

Medical Claim Review --This review evaluates actual charges, billing practices, and the overall medical appropriateness of patient services, including procedures or diagnoses.

Utilization management services are beneficial to insurance companies, employers, and other group health plans and organizations.

PROVIDER DIRECTORY
CONTACT US | REQUEST INFORMATION
HOME | COMPANY HISTORY | PREFERRED PROVIDER ORGANIZATION | UTILIZATION MANAGEMENT | EMPLOYEE BENEFITS AGENCY | MEMBER INFO | PROVIDER INFO | GLOSSARY OF MEDICAL TERMS | STORMONT-VAIL HEALTH LIBRARY | EMPLOYMENT
PRIVACY | SITE MAP