Evolent Health Services

Clinical Services

Drive Positive Clinical Outcomes With A Whole Person Approach to Medical Management

Evolent promotes a whole person approach to member care, meeting physical and behavioral health needs across Utilization Management, Care Management and Population Health Management. Our integrated model and interdisciplinary approach is focused on reducing handoffs and providing a better member experience.

First In Population Health

Evolent was the first organization to earn NCQA Population Health Accreditation, with 3-year accreditation status.

Our Care Management Model Addresses the Needs of the Entire Population

Powerful Predictive Analytics
We employ cutting edge AI and machine learning to define the member journey, real time stratification to identify “impactable” adverse events, and behavioral phenotyping to identify a member’s likelihood to engage.

Robust Library of Clinical Programs and Integrated Workflows
Our pre-loaded, NCQA-compliant, evidence-based clinical programs and rules-driven workflows offer our partners pioneering approaches to improving quality and reducing unnecessary utilization.

Real Time Performance Management Reporting and Insights
Drive continuous improvement across clinical programs with on-demand KPI analytics and performance management reporting, giving you visibility into member outreach, engagement and staff capacity.

The Heart of Care: Addressing Behavioral Health and Immediate Needs Go Hand In Hand During Social Isolation

Learn how our team members used clinical expertise and problem-solving skills to help a member overcome serious challenges.

Delivering Impact Where It Counts

In medical spend (PMPM)

with Complex Care program

In 30-day readmission rate

with Transition Care program

In inpatient admits per 1,000

through Inpatient Review and Oversight Utilization Management policy

In monthly ER visits per 1,000

through Emergency Room Utilization Management initiative

Physician Led Approach to Utilization Management

Evolent’s Utilization Management philosophy centers around partnering and collaborating with providers to ensure members receive the appropriate high-quality care. Our NCQA-accredited approach uses evidence-based medical necessity criteria, with an emphasis on referral to the appropriate Care Management programs. This includes:

  • Inventory of 150+ medical payment and prior authorization medical policies
  • Ability to create new medical policies to meet local market needs
  • Technical assessment review of experimental and investigational services and procedures
  • Ongoing review and maintenance of inventory for clinical practice and preventive health guidelines

Bringing Member Advocacy to Grievances & Appeals
Evolent brings extensive experience to support partners throughout the Grievances & Appeals process, including day-to-day health plan operations, regulatory audits and process improvement.

Audit Readiness
Medicare Advantage plans are subject to strict CMS oversight, and absolute adherence is mandatory. Through years of experience administering utilization management operations, Evolent’s Regulatory Compliance and Audit Execution and Support teams deploy well-tested best practices to support our partners through Medicare Advantage- and state-driven audits, as well as NCQA accreditation surveys.

Powerful Technology
Evolent leverages the Identifi® platform to drive all stages of the utilization management process, including intake, auto-authorizations, prior authorizations, concurrent review, determinations and appeals & grievances.

Learn more about Evolent’s Medical Management Services and Capabilities