The Utilization Management (UM) program provides continuity of care and coordination of services to increase the effectiveness of services and improve health outcomes.
Licensed nurses may authorize services under the direction of the medical director, but they do not make medical necessity denial decisions. They apply UM criteria to make decisions and utilize their clinical knowledge while considering the individual needs of the members. The Plan’s medical director is available to the nurses for consultation and to make medical necessity denials.
Health Services is committed to ensuring medically necessary care in appropriate settings. UM nurses and providers work closely with hospital staff and attending providers to perform pre-service, concurrent and post-service reviews, utilizing nationally recognized, evidence-based criteria adopted by our network of providers to ensure that the services are appropriate.