Effective utilization management programs are based on providing the right patient care at the right time. Outlined below are the 3 best practices employed by the most successful UM programs.

1. Clearly Define Processes, Responsibilities, And Policies

A well-defined utilization review process – that clearly maps out each step in the process and the roles and responsibilities of each team member – ensures quality, repeatability, and sustainability.

Having robust policies and procedures in place that include topics such as the guidelines utilized for admissions/requested services, complete list of professional services offered, and care setting reviews, is critical to the success of a utilization management (UM) program.

2. Utilization Review Program Overseen By A Dedicated Physician Advisor

Experienced Clinicians with a robust knowledge of healthcare policies, UM standards, and revenue cycle processes should provide arching oversight of all UM staff conducting utilization reviews and the UM program itself.

These advisors are imperative to any successful UM initiative as they demonstrate critical thinking, problem solving, and good decision making skill that enable them to see the bigger picture when it comes to patient care – clinical and legal aspects, not solely financial – while providing guidance to nursing staff by sharing their knowledge of best practices and standards of care in their designated field(s) of medicine.

3. Strong Quality Improvement Program

All processes and clinical decision making must be audited to ensure regulatory compliance and appropriate utilization of medical necessity guidelines. Having a strong quality improvement program allows for the audit results to become actionable data.

Staff coaching, providing refresher education, revamping training materials, and updating workflows are just some of the things that can be done based on the quality audits, leading to more competent and consistent staff, more efficient handling of cases, increased quality results, and better patient outcomes.

Shearwater Health is a Full-Service Utilization Management Provider

With 3,000+ experienced clinicians and over 20 years of experience in healthcare, Shearwater Health provides dedicated clinical teams delivering improved quality of care, reduced cost, and improved clinical processes to 8 of the top 10 payers in the industry.

With 98.9% standard quality audits, 97% clinical decision accuracy, and URAC accreditation, coupled with an average 30-65% savings on direct labor costs, Shearwater health can help you scale and manage a successful utilization program.

Contact us today to find out what a utilization management partnership with Shearwater Health can do for your organization.