The Challenge
- Need to cut medical management costs
- Staffing challenges in the UM unit due to turnover and aging workforce
- High cost of recruiting, training, and retaining USRN UM reviewers to support the case volume
- Limited workspace for more nurses in the UM unit
- Member expansion sequelae further increasing case volumes for UM review
- Struggling to meet efficiency in timely completion of UM review resulting to delays in provision of care management for the member
The Solution
- Conducted deep-dive analysis on different UM case types to identify optimal handling time per case type
- Conducted root cause analysis to identify critical factors affecting the efficiency of UM review completion rate
- Developed different sets of decision-trees to streamline and optimize UM case review process
- Worked with the client to integrate functionalities for their system upgrade addressing the identified critical to UM efficiency factors
- Re-educated the client’s upstream process personnel to avert case breaks and case flow system errors affecting UM review nurses
- After deep-dive analysis, Shearwater identified additional UM case types and complexities where Shearwater UM Reviewers can be trained on to further help the client on increasing case volumes
The Strategy
Dedicated Clinical Team of USRNs
Scalability with "Train the Trainer" Program
Six Sigma Business Excellence
The Results
69.59%
Reduced Overall Case Handling Time
41%
Improved Efficiency
25%
More Daily Case Completions
95%
Quality Benchmark Consistently Met or Exceeded
