Utilization Management Program

Utilization Management Program

INTRODUCTION

Nevada Health Solutions’s Utilization Management Program is multi-dimensional and operates to direct and monitor the use and quality of health care services provided to its patients. The Program includes pre-services, concurrent, and retrospective review and evaluation of the utilization of services provided to patients.

It is designed to optimally manage healthcare resources to maximize the cost effectiveness and quality of the care provided to patients. It is structured to promote fair, safe and consistent utilization management decision-making. The Program is under the clinical supervision of the Medical Director, a Nevada licensed physician and the Senior Director of Medical Management, a Nevada licensed RN, both providing support to develop and implement the Program.

The Program is updated as necessary and is evaluated and approved annually by the Utilization Management Committee and the Quality Committee.

The following summary highlights some of the primary functions of the Utilization Management Program that serves to ensure patients’ easy access to the most appropriate and efficient quality care to promote improved health outcomes.

PURPOSE

The purpose of the Utilization Management Program is to provide a comprehensive, integrated process that ensures patients in all age groups from new born to geriatrics receive timely, safe and appropriate medical care in the most efficient and cost-efficient manner. The Program provides a comprehensive process of review of inpatient and outpatient medical services for self funded and commercial plans as contracted. This process assures the delivery of medically necessary, optimally achievable, quality patient care through appropriate utilization resources in a cost effective and timely manner. The focus of the Program is to ensure efficiency and continuity by identifying, evaluating, monitoring and correcting elements that affect the overall effectiveness of the utilization management process. The Program’s activities are developed and implemented in compliance with state and federal regulations.

Moreover, in order to continually assess and improve the quality of care available to patients, the Program interfaces with the Quality Committee to facilitate the achievement of its goals and objectives.

 

Click here to view the UM Program Description