Utilization Management

Control healthcare costs while improving patient outcomes

Reducing unnecessary and/or inappropriate provision of services is crucial to managing healthcare costs and encouraging the highest quality of care. To enhance profitability and patient outcomes, healthcare payers must efficiently review and decide on the necessity and appropriateness before, during and after services are provided.

Firstsource’s Utilization Management services help payers reduce costs while managing growing document and case volumes with greater accuracy and efficiency. Using evidence-based criteria, we review multiple types of information across your universe of health plan members – including documents, cases and letters – and ensure rapid, accurate and appropriate clinical validation from nurses and hospitals. Our utilization management services also help free up your in-house clinical teams, enabling them to focus more of their time on patient outcomes and other critical activities.

Your expert document and case review support team

  • Document accuracy review, administrative and clinical decision support
  • Outreach calls performed by knowledgeable, full-time staff with clinical review experience
  • Operational efficiencies across the patient healthcare lifecycle
  • Utilization and cost analysis of members’ use of benefits

Payers understand the importance of clinical knowledge in their ability to review cases for medical necessity and make appropriate decisions. Firstsource provides professional administrative and clinical agents, leading-edge technology and intelligent, automated solutions that improve the utilization review and decision-making process.

Our end-to-end process combines the knowledgeable staff, high capacity, flexibility and automated workflows payers need to accurately and efficiently complete dozens or hundreds of cases per day. The result is system and workflow efficiencies that can be further expanded through integration with Firstsource’s digital mailroom, document, denial and customer management services.

Document Workflow, Case Reviews, Alerts and Authorizations

Firstsource’s utilization management provides complete review coverage before, during and after the rendering of services to appropriately influence patient care decision-making.

Document Workflow and Case Reviews

  • Outpatient/Inpatient document and letter verification including fax queues
  • Clinical workflows with nurses and clinicians to review cases and letters
  • Document routing to the requesting providers

Alerts and Authorizations

  • Prior, concurrent and retrospective reviews and authorizations
  • Provider and member notifications on decided open cases
  • Document alert notifications built into workflows
Stay Ahead

Efficient Utilization Management

Knowledgeable staff, high capacity, flexibility and automated workflows that payers need to accurately and efficiently complete hundreds of cases per day.

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