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Utilization Management

Our utilization management program supports both providers and members by providing trusted information. Our focus is on the identification, facilitation, and implementation of best practices in the delivery of quality, cost-effective care. 

What does utilization management do and what services are included?

Utilization management has two components: inpatient services and outpatient services. Our inpatient services are responsible for all inpatient authorizations, including skilled nursing facility authorizations and all behavioral health and substance abuse authorizations (inpatient and outpatient). Additionally, our utilization management outpatient services are responsible for ensuring quality care and comprehensive management for all members. Our outpatient team works in tandem with our inpatient team in coordinating preauthorization and level-of-care reviews.  


What is the value of these services?

  1. Identify barriers of care
  2. Monitor treatment utilization
  3. Ensure medically necessary treatment is provided 
  4. Ensure members are receiving adequate and appropriate care at the right facility and at the right time


What health professionals make up the utilization management team?

Our utilization management team consists of several different types of health professionals:

  1. Outpatient services include medical directors, registered nurses (RNs), and associates.
  2. Inpatient services include registered nurses (RNs), licensed clinical social workers, licensed practical nurses (LPNs), medical associates, master-level social workers, and medical directors


Interested in enrolling or learning more?

Outpatient Services: Call 800-677-3086, option 2.

Inpatient Services:  Review your prior authorizations, and learn more about the following. 


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