Utilization Management

			Manage medical costs through care coordination and utilization review to create a financially sound foundation for your healthcare strategy.
				Utilization Management Product Sheet

Carewise Utilization Management strives to prevent over-utilization of healthcare services by maximizing the quality of healthcare delivery and avoiding unnecessary healthcare costs. In alignment with the benefits plan, Carewise Health provides pre-certification and concurrent review for inpatient admissions, outpatient surgeries, procedures, therapies, services, and home healthcare.

• Integration point. Utilization management, when paired with Carewise Condition Management, creates an opportunity for early identification of individuals who may benefit from nurse counseling services.
• Customized review process. At least 24 months of claims data is reviewed against industry standards to create a customized review list for each client. This utilization review includes inpatient and outpatient services, as well as other high-cost services such as durable medical equipment.
• Care coordination and discharge planning. Carewise Utilization Management assists individuals with navigating the healthcare system and manages each case, from pre-certification through discharge planning, to ensure compliance with medical standards.

Carewise Health is marketed by SHPS, Inc., a provider of integrated health solutions. SHPS has been providing utilization and case management programs since 1985. Independent of the health plan, Carewise Utilization Management encourages responsible use of healthcare services through pre-op counseling, discharge planning, and overall decision support. It’s configurable to meet the unique needs of our large employer clients and achieve key financial and clinical goals.