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.