Shearwater creates Group Health CPO™ solutions based on a client’s specific needs and objectives, which have proven to eliminate unnecessary medical expenditures, improve results and increase efficiency for the health care plans we serve.
- Fully compliant with URAC standards
- Fully compliant with state licensure where required
- Work from clients’ existing software systems to provide seamless interaction and prompt service
100% of Shearwater utilization reviews are customized to client rules and specifications. These solutions include:
- Management and concurrent review of patient records either online or by telephone to determine medical appropriateness consistent with approved guidelines
- Authorization and pre-certification to collect information prior to hospital or outpatient facility admission
- Review of requests not fully adjudicated
- Appeals assessment using client-specific guidelines to ensure appropriate administration of benefits
- Provider representation for pre-authorizations;
- Retrospective reviews for quality assurance.
Shearwater provides preliminary clinical reviews for utilization management cases.
- Key in physician orders and intake documents into clients’ utilization management systems
- Reviewing and act upon these orders according to the application of specific, nationally recognized and evidence-based guidelines.
- Ensure medical necessity and appropriate protocol
With a clear understanding of the complexities of HEDIS reporting, Shearwater provides experienced clinicians able to expertly carry out HEDIS abstractions.
- Complete collection of all medical records, accurate abstractions and analyses of the required data
- Highest quality assurance
- Timely delivery of results
- HEDIS partner to Top 5 payer and payer services companies currently experiencing a 4+ STARS Rating
- Quality rate across our HEDIS clients is greater than 98%
- Over 25 years of combined HEDIS Account Management experience
- Singular Shearwater workforce closes care gaps for STARs Maximization and adjusts workflow to abstract patient records during the HEDIS season
- Annual training accommodates client and auditor changes, validates Shearwater nurse reviewer competency
- Priority populations drive customization of HEDIS and STARs workflow
Shearwater can provide registered nurses to prospectively advise providers and patients/health plan members of specific procedures, tests or studies they should obtain in order to optimize health and ensure that the health plan earns the proper STARs rating as well as financial payment based on the quality of health care delivered to its members.
Telephonic (Inbound/Outbound) Services
Shearwater provides 24/7/365 direct in- and out-bound telephonic interaction with our nurses and other health care professionals.
This service is operated on a system that integrates seamlessly with our clients’ telephone systems and allows their members to answer all questions regarding clarity of physician orders or patient medical records, confirm demographic materials for patients or providers, request additional information or address any other matter in accordance with our clients’ policies and procedures.
Medicare Risk Adjustment
We have experienced health care professionals as well as advanced technology to accurately decipher and code medical records in order to provide the necessary evidence to support risk scores for Medicare managed health plans. Through advanced data analysis, abstraction and verification systems, Shearwater delivers workforce augmentation strategies to support proper coding and to ensure appropriate financial payment within the Medicare environment.
Other payer services
Shearwater is an expert at organizing and deploying clinical resources, including physicians, nurses and pharmacists, in creative and innovative ways to meet the unique needs of health plans. We welcome the opportunity to solve any medical management need.