Utilization Management


Carewise Health Utilization Management services are a gateway to medically appropriate services for members.

Types of Services

Carewise Health Utilization Management is a gateway to medically appropriate services for members.

  • Pre-certification: Carewise Health evaluates medical appropriateness by applying standard guidelines or by having the proposed service reviewed by an on-site medical director. For services not certified, expedited and standard appeals also are provided.
  • Concurrent Review: Carewise Health monitors the treatment delivered to the member on each day of hospitalization, along with the member's response to treatment and health status
  • Discharge planning: Prior to discharge, the nurse identifies the resources and support that will be needed to ensure a safe transition to home recuperation
  • Care coordination: If a member will need rehabilitation services, sub-acute care or home-care services after discharge, Carewise Health will identify qualified network providers, make the necessary arrangements and monitor that the therapeutic intent of service is being met

Early referral of high-risk cases: If used as part of a total health-management solution, Utilization Management will refer members with acute recovery risks to Carewise Case Management at the time of pre-certification. Additionally, those members with chronic conditions will be encouraged to take advantage of Disease Management resources and engage with a Carewise nurse as soon as it is appropriate.

Population-based utilization profile: We will conduct a detailed claims analysis of the last 24 months to identify variances from industry benchmarks and opportunities to reduce over-utilization. This profile becomes the foundation for a strategy that is uniquely appropriate to your population.

Our Staff

Utilization Management reviews are performed by registered nurse specialists with diverse clinical backgrounds. Nurses working in this team have medical-surgical experience and direct knowledge of accepted clinical practice guidelines, proactive procedures, discharge planning, concurrent planning, precertification, and clinical case appeals. They understand quality, risk, and cost concerns in the provision of patient care. By coordinating health care benefits, they ensure patients are receiving quality care at the appropriate level, and at the least costly but most effective treatment benefit.
Our case management programs are accredited by URAC. URAC’s mission is to promote continuous improvement in the quality and efficiency of healthcare management through processes of accreditation, education, and measurement. Carewise’s program is accredited in nine core disease states as defined by the Disease Management Association of America.