Utilization Management

Utilization Management is the review of the medical necessity, appropriateness and efficiency of the use of healthcare services under the provisions of the health benefits plan. This service begins with pre-certification requirements that are designed to ensure all members receive the right care at the right time. We routinely work with our customers to tailor and update pre-certification lists to keep up with industry and book of business trends.
Our Utilization Management professionals work with members before they receive care and while they receive care to ensure the most appropriate treatments are given. Our nurses, supported by a full panel of physician specialists, review all inpatient and outpatient services received to: ensure doctor orders are carried out in an efficient and accurate manner, identify questionable medications or procedures, plan ahead and monitor the member's progress. By working closely with healthcare providers, we give members information and options that can reduce hospital stays and speed recovery.