Utilization Management

Ensuring clinically proven, cost-effective care

When medical issues arise, patients need prompt and personalized service – always at the appropriate level of care. Utilization Management from Vālenz® Health ensures the right care at the right place and time, paving a more cost-effective path to healthy outcomes.

As soon as we are notified of a new diagnosis or treatment recommendation, our highly trained Utilization Management nurses conduct a clinical review to determine medical necessity and ensure alignment with the most appropriate level of care according to evidence-based guidelines for that diagnosis. To deliver cost savings for the plan and plan members, we combine those guidelines with advanced analytics from our Valenz platform to facilitate high-quality care while eliminating expenses tied to unnecessary, unproven or excessive treatments.

Benefits of Utilization Management

Pre-certification and coverage verification

We provide custom-built pre-certification services, and we assist members by verifying coverage before services are rendered.

Case management referrals

Our clinical review also identifies when case management is appropriate, and we manage the steps to facilitate that process.

Eliminating unnecessary costs

Our services ensure clinically sound patient care while safeguarding against costly tests, procedures and hospitalizations that are not needed.

Prompt service for members

Our team reviews and responds to inpatient requests within 72 hours, so patients have access to care as quickly as possible.

Pre-Certification Opportunities

The following services may benefit from precertification, depending on your plan’s coverage:

  • Maternity longer than federal mandate
  • Inpatient medical, surgical and pediatric care
  • Mental health and substance abuse
  • Skilled nursing and long-term acute care
  • Home health and durable medical equipment
  • Physical rehabilitation and physical, occupational or speech therapy
  • Cardiac and respiratory rehabilitation
  • CT scans, MRIs, MRAs, PET scans and bone scans
  • Pain management procedures
  • Dialysis
  • Infusion therapies and specialty injectables

URAC Accreditation

With our URAC-accredited Utilization Management solution, we  align costs and quality of care by engaging early to quickly identify high-risk cases. Learn more about our URAC-accredited Disease Management and Case Management solutions, two additional solutions from Valenz that lower costs and improve care.

Health Utilization Management
Disease Management
Case Management

The Smart Way to Invest in Member Health

Valenz Care Management solutions – Case Management, Disease Management and Utilization Management – yield an average ROI of 8:1.