Utilization Management

Utilization Management Services

Reduce Denials. Improve Costs.

Dedicated teams of experienced and trained clinicians cross-trained across specialties to scale to your needs.

Your Full-Service Utilization Management Provider

Support across all phases of the Utilization Management lifecycle

Intake

Fax, Phone, Web

Intake

Receiving the request and creating a case number for clinical review

Clinical Review

InterQual, MCG, CMS, Client Proprietary Guidelines

Clinical Review

Reviewing the request for medical necessity and approving the case if it meets the required guidelines

MD Review Support

MD Review Summarization, Peer Review Quality Assurance

MD Review Support

Supporting physician reviewers for faster and more accurate determinations

Post-Decision Support

Verbal, Written

Post-Decision Support

Notifying the requestor of approval or denial via letter or phone

Appeals & Grievances

Intake and Clinical Appeals

Appeals & Grievances

Reviewing member and provider appeals to assess if the denial was warranted or not

Deep Experience in Utilization Management

Upholds URAC 'gold star' accreditation

Dually accredited in HUM and WCUM across delivery centers

Over 500 nurses perform Utilization Management

Cross-trained for scalability across specialties

Training, Quality, and Operations

Supported by Utilization Management subject matter experts

Physician on-staff as clinical lead

Utilization Management offering provides direction from processes to management

Fill specialized Utilization Management roles for clients

Appeals & Grievances Trends Specialist, CMS Audit Specialist, Quality of Care Investigators, Medical Claims Reviewers, USPTs

Poor Quality is Costly. At Shearwater Health, Quality is Our Top Priority.

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Annual Reviews

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Standard Quality Audits

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Clinical Decision Accuracy

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Nurses Specializing in Utilization Management

Shearwater's Deep Utilization Management Capabilities

Intake

Intake via phone, fax, web
Clinical case building
Appointment coordination

Summary

Office visit notes
Clinical scenarios
Patient history compilation
Packaging for next-level review
Peer to peer coordination

Determination

Review request vs. MCG, InterQual, CMS or client-specific guidelines
Gathering additional information necessary for determination
Determination of appropriateness

Post Determination Support

Determine letters
Outbound telephonic determination communications

Appeals & Grievances

Intake
Summary
Determination
Post-Determination Support
Member & Provider Appeals
Non-Clinical Appeals