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 Care 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 Vālenz ecosystem 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 Care that lower costs and improve care.

The Smart Way to Invest in Member Health

Valenz Care solutions – Case Management, Disease Management and Utilization Management – yield an average ROI of 10:1.

Experience the Synergy

When we say the Valenz ecosystem is comprehensive, we mean it. With a complete selection of fully integrated wraparound solutions to complement the core solutions featured below, we deliver benefits far greater than the sum of all these parts individually.

Vālenz Access

Combine a quality-first provider network or open solution with a range of customized, data-driven services from the Access Solutions Suite.

Vālenz Care

Guide members to better care and outcomes at lower costs, for you and for them, with RN-led, triple URAC-accredited care management.

Vālenz Claim

Reduce costs and ensure accurate payments with comprehensive bill reviews and repricing methodologies, integrated analytics, and more.

Vālenz Assurance

Improve coding, reimbursement assurance, auditing, claim accuracy and compliance monitoring, all while saving time and costs.

v-Lens

Use advanced, drill-down analytics and predictive modeling to continuously disrupt the cost curve without compromising quality.

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URAC Accreditation

Valenz Care programs are accredited by URAC, a testament to our commitment to advancing healthcare quality in support of smarter, better, faster healthcare.