Utilization Management

The goal of Amalgamated Medical Care Management’s Utilization Management programs is to facilitate the most effective use of medical resources, while also promoting optimal patient outcomes. An experienced team of Registered Nurses provides comprehensive medical oversight, the application of evidence-based criteria and guidelines, medical appropriateness, patient setting-driven considerations, level of care determinations, and quality of care parameters. Applying this thorough approach, they deliver Utilization Management programs that effectively meet the needs of healthcare plan sponsors including, unions, trust funds, ERISA plans, state programs, businesses and associations and health plans, as well as other care management firms. Reflecting today’s value-based healthcare objectives and new healthcare models from accountable care organizations to patient-centered homes, Amalgamated Medical Care Management’s Utilization Management programs are designed to:

  • Encompass hospital and medical pre-certification, concurrent review, discharge planning, appeals and retrospective review;
  • Promote optimum utilization of healthcare resources and cost containment;
  • Consider the medical necessity for inpatient stays (i.e., acute, behavioral and residential), and outpatient resources (e.g., diagnostics, other medical tests, therapies, infusion, durable medical goods, etc.);
  • Mitigate risks by addressing regulatory mandates; and
  • Support goals relating to population health management.

Amalgamated Medical Care Management’s Utilization Management programs are distinguished by these important features:

  • An experienced team of registered nurses and physicians overseeing the full range of clinical services and settings including specialty programs;
  • Available on a 24-hour basis with the ability to ”wrap-around” the Utilization;
  • Management services on an existing program for night, weekend and holiday coverage;
  • Accredited to URAC standards; and
  • In full compliance with the Department of Labor’s (DOL) standards for ERISA self-funded groups.

In the past few weeks there have been numerous restrictions placed on businesses throughout the United States. Many states and localities across the country have enacted temporary restrictions on non-essential business operations, requiring millions of workers to stay home. Amalgamated Life Insurance Company, which is based in New York, is considered an essential business and therefore is not subject to these temporary restrictions.

However, in an effort to protect the health and safety of our employees, their families and communities, we have taken a series of company-wide actions, across all Amalgamated Family of Companies locations, to implement work from home and other flexible arrangements where feasible. Despite these changes, we will continue to provide you and your members with the customer service levels you have come to expect from us prior to the coronavirus outbreak.

We are diligently working with our partners and vendors to utilize our remote capabilities and infrastructure. We are also in constant communication with UPS and the USPS to stay informed of any potential changes in service. For the duration of this state of emergency, Amalgamated Life Insurance Company will comply with any required Notice Obligations by emailing and/or mailing notices to all consumers.

If you have any questions or concerns please reach out to your Amalgamated Family of Companies representative or our customer service center at: 914-367-5000. They are well-prepared to answer your questions and can address your specific needs.