Transforming Utilization Management

Utilization Management (UM) products use evidence-based guidelines to determine appropriate healthcare service, setting, and level of care at quality standards for patients. UM is able to support intake and decisions and case and workflow management such as, prior auth determination, post-submit auto authorization decisions and medical necessity validation and recommendations. It is also crucial in supporting evidence based clinical guidelines to validate and determine medical necessity and recommend level of care and length of stay and clinical redirection to qualify and recommend appropriate site of service upstream that translates to optimizing costs, value and overall experience.