Utilization Management

APPROPRIATE AND TIMELY UTILIZATION

Evolent Utilization Management aligns your health system’s quality goals with the need to reduce inappropriate utilization and improve member and provider satisfaction. Our team implements best-in-class UM practices, including technology-powered workflow, medical policy decision support and analytics. Utilization Management is a delegated offering that is NCQA-certified and supports prior authorization, transitions and appeals oversight.

UTILIZATION MANAGEMENT BUILT BY AND FOR PROVIDERS

Maximize Impact

Through a physician-led model that delivers appropriate care while playing a key role in medical necessity determinations

Coordinate Seamlessly

By equipping UM nurses with the same data and insights used by physicians and care managers

Interoperate Broadly

Through connectivity with multiple claims engines including NASCO®, HSG®, Facets®, OAO® and MC400®, as well as Medical Policy Decision Support systems McKesson InterQual® and mcg®

Reduce Uncertainty

With an NCQA-certified delegation program that provides a reliable path for health plan accreditation

OUR OFFERING

TECHNOLOGY

Workflow is specifically designed for provider-based UM with integrated support for medical policy decisions and service level agreement prioritization, offered through our Certified Alliance Partnership with InterQual® and compatibility with mcg®

UM PROGRAM

Execute a high-performing UM program with our fully packaged UM policies and procedures, medical policies and pay policies, including committee membership for medical policy development and technology assessment

NCQA-CERTIFIED DELEGATED UM

Full delegation to Evolent includes a suite of services comprised of a prior authorization team, local inpatient UM staff for acute hospital reviews and high-risk transitions program, appeals staff, full operations management, regulatory compliance oversight, Utilization Management committee oversight, and UMC reporting to QIO

REPORTING AND ANALYTICS

Manage performance and gain actionable insights through our self-serve reporting and analytics capabilities, providing UM and appeals reports for inpatient and outpatient utilization, inpatient trend dashboards, UM productivity, appeals outcomes and provider overturn rates

Ready to learn more?