Data Sheet: GuidingCare Utilization Management
Managing the utilization of benefits is a complex, time-consuming task that often requires extensive human resources. The lack of connectivity and modern technology further complicates the process, making it cumbersome to engage multiple stakeholders and review evidence-based clinical guidelines.
Addressing Challenges with GuidingCare Utilization Management
GuidingCare Utilization Management by HealthEdge streamlines the utilization review process for health plans, enhancing efficiency through automation and seamless access to clinical guidelines. This solution supports custom configurations to meet your organization's specific needs, resulting in improved business efficiencies and better outcomes for members and providers.
Key Features and Benefits
Effective Authorization Lifecycle Management
GuidingCare Utilization Management supports the entire authorization lifecycle, creating a connected ecosystem that delivers real-time data throughout the process. Key features include:
Automated Workflows:
- Pre-populated data templates for authorizations, reviews, and service approvals.
- Configurable and clinically sound workflow management.
Support for Every Stage:
- From request and review to status determination and correspondence.
Integration with MCG and InterQual:
- Automated decisioning with MCG Cite AutoAuth and InterQual Connect™.
- Direct access to evidence-based clinical guidelines.
Instant Clinical Guidance Transfer:
- Instantly transfers evidence-based clinical guidance into the member record to support authorization requests and appeals.
Comprehensive Data View:
- Consolidated view of current and historical health and encounter details, authorizations, and correspondence.
Configurable Turnaround Time (TAT):
- Tailored TAT by benefit program and authorization type for review, approval, and correspondence activities.
Real-World Results
Ann Donnelly, Priority Health:
"[With GuidingCare], we now have the data that shows us by service, how many prior authorizations are coming in, how many we are approving, how many we are denying, and what they cost. We can make educated decisions on the value of asking for that prior authorization, and if there’s no value in it, then why are we asking physicians to jump through them?"
Delivering Results for Digital Payers
Digital payers leverage advanced connectivity, automation, and real-time data to achieve better outcomes through the utilization review process. Benefits include:
- Enhanced collaboration and outcomes.
- Real-time access to member information for CM and UM staff.
- Improved compliance across all lines of business.
- Streamlined authorization and decision workflows.
- Time savings and improved accuracy.
- Addressing NCQA level requirements.
Why Choose GuidingCare?
The GuidingCare Utilization Management module is part of HealthEdge's comprehensive suite of solutions, designed for care management. This platform supports care management, utilization management, appeals, grievances, authorizations, and population health in a fully integrated, next-generation solution. HealthEdge delivers a digital foundation for payers, enabling digital transformation, cost reduction, and improved clinical outcomes and member experiences.
GuidingCare Utilization Management is an essential tool for health plans seeking to enhance their utilization management processes through cutting-edge technology. By streamlining workflows, providing real-time data, and integrating evidence-based clinical guidelines, GuidingCare helps organizations improve efficiency, compliance, and overall outcomes.
Learn more about GuidingCare Utilization Management
For more information, visit HealthEdge at healthedge.com or contact [email protected].
