Utilization Management is a process that ensures client/support systems receive needed care and services in the necessary care setting by the appropriate care provider. Utilization Management applies across the continuum of health and human services. It manages and evaluates healthcare resources used to meet the requirements of the applicable health benefit plan in providing the highest quality in the most cost-effective and efficient care setting. The areas of focus are clinical care, reimbursement, denials, transition of care, and evaluation.
Utilization Management Evaluates
The medical necessity for services to be provided, including the level of case used
The appropriateness of services rendered based on the applicable health benefits plan
The efficiency of healthcare services used (e.g., interventions, treatments, test, procedures)
The relevance of the healthcare organization and/or provider to the services rendered
Risk stratification to identify high-utilizers, high-risk readmissions, and areas of high cost
Resource management (e.g., recapture care, continuity of care, pharmacy utilization, high-utilizers)
Interdisciplinary collaborations (e.g. direct and purchased care)
Prospective, concurrent, and retrospective utilization reviews/quality management
Oversight of in-patient discharge planning function
Performance and outcome measure reporting (e.g., variance tracking, trending)
Benefits of Utilization Management
Utilization Management department obligation is to you and to the organization. The UM team will coordinate your services, reduce unnecessary costs, and facilitate transitions of care while balancing your needs within the limits of available benefits (coverage) and community resources. The UM team ensures that the care you receive is of high quality, efficient, and cost-effective.