Best Utilization Management Software - Page 4

Utilization management software provides hospitals and health care practices a process with which to evaluate health care services and procedures provided to patients to determine their medical necessity. Health care administrators depend on utilization management processes to ensure that their physicians are maintaining a high quality of care and administering effective treatments while minimizing costs. Utilization management review and determination can occur before (prospective utilization review), during (concurrent utilization review), or after (retrospective utilization review) patient treatment has been scheduled and provided; software supports action during any of those three stages. Additionally, utilization management software has the potential to better the working relationship between providers and payers. By leveraging patient data found in EHRs, health care providers can apply real-time data to the review process, adhere to regulations, and optimize revenue cycle management. Registered nurses equipped with utilization management certification, case managers, and physicians are the main players during the review process.

To qualify for inclusion in the Utilization Management category, a product must:

• Set up trigger workflows
• Automate approvals and authorizations of medical services and procedures
• Simplify or automate reviews of medical services and procedures
• Aggregate clinical and financial data across a health care organization
• Integrate with EHRs or easily leverage EHR data to trigger relevant workflows