Traditional Utilization Management

 

Determines medical necessity of medical services.

The clinical professionals providing American Health’s Utilization Management services use established national medical guidelines to evaluate the medical necessity for hospitalizations and outpatient services and the appropriateness of the overall treatment plan.  Our programs combine the expertise of registered nurse reviewers, our board certified Medical Director and a panel of board certified, practicing physicians to help direct patients and their providers towards the most cost effective, quality treatment available.

 

Fast Facts

• American Health’s Utilization Management program is accredited by URAC.
• The service is guided by American Health’s Total Quality Management Program, which sets the highest priority on timeliness, accuracy, quality of care and cost-effectiveness.
• Each admission evaluation is conducted by a registered nurse reviewer who applies established medical criteria that meets national and community standards.
• The reviewers interact with attending physicians to agree on treatment plans and appropriate lengths of stay.  Cases are continually monitored throughout the hospital stay to assure quality and appropriateness of care.
• All nurse reviewers have at least 5-8 years of clinical experience.  They view the best patient outcomes as their goal.
• The review also benefits from American Health’s own state-of-the-art computer system.  The system was designed to facilitate all of the steps in the utilization review process – from initial patient or provider contact, through evaluation and recommendation, culminating with discharge planning.

Medical Director and Panel of Specialists

Overseeing the Utilization Management program is a Medical Director certified by the American Board of Quality Assurance and Utilization Review Physicians.  The program also offers the expertise of American Health’s own panel of board-certified, practicing physician specialists, in addition to external panels of more than 600 specialists.