Utilization Review

Inpatient Care Nurses work with patients and providers to serve patients' best interests to ensure that appropriate care is delivered in the most cost effective setting. Nurses evaluate and determine medical necessity and setting appropriateness for each requested procedure. Issues explored include whether a continued stay is necessary to achieve the desired result and whether there are cost effective alternatives available without sacrificing care. Our goal is to utilize nurse services that help keep patients healthy by making sure they obtain the right care, at the right time, in the right setting.

Outpatient Care Nurses focus on high cost, high utilization outpatient procedures. As medical technology for outpatient treatment has evolved and become more sophisticated, the volume of outpatient procedures and associated costs have risen. Employers have seen outpatient costs parallel those of inpatient costs. Outpatient care management helps our clients control these expenses.

The Utilization Review team of physicians and review specialists draw from a broad spectrum of clinical experience to perform the following functions:

  • Inpatient Review
  • Outpatient Review
  • Concurrent Review
  • Discharge Planning
  • Referral Management
  • Network Channeling

When a member, dependent or provider initiates a call to utilization management, that encounter must be used to address and evaluate the use of in network providers, expectations regarding length of stay or length of care, medical necessity, and appropriateness of setting and anticipated future care needs.