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Utilization Management
A member-centric view contributes to Utilization Management outcomes that address the whole person’s care.
Improves outcomes for patients, streamlines entry for providers, and equips clinicians with a 360-degree view of the member. Based on nationally recognized clinical standards and guidelines, the Utilization Management (UM) Module is comprehensive and easy to use.
How We Help:
Intake / Eligibility
Integrated eligibility for member and benefits review with personalized authorization workflow.
Integrated National Guideline
Integrate with national evidence-based standards and custom criteria sets.
Streamline Workflows
Streamline workflows and integration with EMR.
Approval Automation
Custom system rules based on the client's data and provides recommended procedures automatically approved within the system reducing delays in care.
Network Steerage and Gold Carding
System ability to redirect in-network providers. Ability to flag high quality providers for auto-adjudication of service requests.
Track Appeals and Grievances
A self-contained appeals and grievances module with the ability to interface with existing appeals and grievance systems streamlines the appeals process.
Reporting and Performance
Reporting on administrative, financial and operational metrics; report library and custom reporting availability.
Features and Functionality
- Medical, behavioral health and pharmacy authorization
- Dental and vision authorization
- Track cost savings
- Network integration
- Track authorization history
- Provider portal
- Integration with pharmacy databases
Combine these modules for even greater benefits:
Care Management
Our holistic approach to case management encompasses physical and behavioral health as well as social determinants of health.
Capabilities
Population Identification
Real-time Communication
Multidisciplinary Assessment
Evidence-Based Care Plans
Rule Driven Interventions
Social Determinants Of Health
Reporting And Performance
Akumen™
A dynamic analytics platform leveraging AI-based predictive modeling and data-driven decision-making to manage risk.
Capabilities
Cloud-based Architecture
EMPI for Member and Provider
Stratify Populations for Vaccines and Wellness
Personalized Metrics for Outcomes
Predictive Insights
Boosts Efficiency