Utilization Management Strategies
The effective use of
services is crucial to maintaining a health plan that is both
high-quality and affordable. Proper utilization management is not
primarily concerned with denying access to services, but rather,
insistent upon appropriate use. Appropriate use may mean increased
access to care that ensures people are getting what they need when
they need it. St. John's utilization management strategies include the
following:
Monitoring quality
and cost of care delivered to health plan membersUtilization monitoring of health care resourcesReferral
authorizations and for specialist and ancillary carePrecertifications
for hospitalization, diagnostic and surgical proceduresAssessment of
whether treatment is appropriate and medically necessary, based upon
accepted criteria, clinical pathways and consulting physician reviewAiding in discharge
planning and continuation of care
How We’re Different
All of our programs
are developed, reviewed and updated with St. John’s Health System
involvement and oversight at every level. A local Medical Director is
available to provide timely decisions.
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