Payers, health plans, Managed Care and Coordinated Care Organizations (MCO/CCO), Third-Party Administrators (TPA) and benefit administrators are all looking to streamline their utilization management review operations and make them as efficient as possible. Prior authorizations, the continuation of care and medical necessity evaluations are increasingly a challenge for many payer organizations. With a scarcity in nursing and physician advisor resources, plus volume fluctuations, it’s increasingly tough for many organizations to staff for and manage these critical functions. And with many demands on in-house Medical Directors, many payer organizations are increasingly partnering with companies like AllMed for processing their incoming service requests.
AllMed has been supporting utilization review and appeals departments for over 25 years, providing flexible services that align our workflow with your needs. We cover the spectrum of standards as dictated by your clinical protocols, including in-house medical policy, plan language, published care guidelines and latest standards of care.
Nurse and Physician Utilization Management Reviews
AllMed offers prior authorizations, pre-certifications, concurrent reviews and retrospective reviews to align with your needs at every stage of your clinical operations processes. Our services for utilization management in healthcare include both generalist and specialty-matched options for the management of utilization for high-volume specialties and treatments.
Physician Generalist Reviews
Nurse and physician reviews to augment your internal capabilities
Specialized expertise for standard of care and complex procedures
High quality decisions by specialists, delivered to the standards you expect
Utilization Management Scope of Services
Determination Notifications (Nurse & MD review levels)
Customer Service Reports
Medical Review Products
Our review products cover a spectrum of needs, including first-level prior authorizations, complex and critical claims, appeals, medical director services and staffing services.
Our In-House Utilization Management Team
AllMed’s services are delivered by our in-house clinical team of utilization management nurses, physician advisors, and clinical copy editors. Our Medical Director team provides clinical quality oversight to all review operations, including case-related troubleshooting as well as Inter-Rater Reliability (IRR) programs.
Whether you are a utilization management department within a health plan, a medical management organization, or specialty benefits manager, we work closely with you to define your requirements, design a UM program that integrates with your systems, train your personnel. Our Program Directors and Account Executives work closely with you through pilot deployment to full volume implementation.
Superior Quality That Makes a Difference
All of our services are deployed through PeerPoint®, AllMed’s advanced medical review portal, which embeds healthcare intelligence and automation tools that produce the highest quality reviews at industry-leading turnaround times and costs.
But what really makes us different is our people. Our commitment to consistently exceeding our clients’ expectations through everything we do, is why AllMed’s clients remain loyal partners, year-after year. This is because of the special care we take to recruit the highest quality talent as well as train, grow, and engage them in our Lean management system. As a values-based company that puts culture first, our employees care deeply about each member’s health and about delivering the highest quality care.
Interested in our review services?
Whether you need specialized expertise or added review capacity,
we’re here to help with customized services that fit your exact needs.