Medical management model

Utilization Management

Our Utilization Management (UM) program uses an integrated medical management model based on the physical, behavioral and social needs of members. The UM program, in collaboration with other departments, such as Case Management and Condition Care, facilitates the delivery of the most appropriate medically necessary care to members in the most cost-effective, least-restrictive setting.

By collecting individualized data, from intake information upon enrollment, historical claims data and ongoing concurrent review, we develop a predictive model that stratifies members into levels of care that determines the level of intervention. Stratification is refined and targeted to those conditions and episodes of care that are most impactful. The care plans developed based on this information are specific to a member’s needs. The member’s provider(s) are also engaged in the development and execution of the plan so the care is integrated across physical, behavioral and social spectrums.