Data Sheet: GuidingCare Utilization Management & Appeals and Grievances
Managing members’ utilization of benefits is a complex and time-consuming, yet necessary task that often requires extensive human resources.
The healthcare industry is grappling with the complexity and inefficiency of utilization management due to disconnected processes, multiple stakeholders, and the need for extensive human resources. HealthEdge’s GuidingCare® Utilization Management module offers a solution to these challenges through advanced connectivity, automation, and real-time data, specifically designed for digital payers.
Key Features
- Streamlined Workflows: Automates business processes and integrates evidence-based clinical guidelines to enhance efficiency.
- Comprehensive Authorization Lifecycle Management: Supports every stage from request to decision, ensuring seamless communication with members and providers.
- Configurable Templates: Includes pre-populated data templates for authorizations, reviews, and service approvals, tailored to organizational needs.
- Real-Time Data Integration: Facilitates instant transfer of clinical guidance into member records, supporting authorization requests and appeals.
- Consolidated View: Provides a holistic view of current and historical health data, authorizations, and correspondence.
- Customizable Turnaround Times: Allows organizations to set review, approval, and correspondence timelines by benefit program and authorization type.
Benefits for Digital Payers
- Enhanced Collaboration and Outcomes: Facilitates better teamwork and results through seamless access to member information for care management (CM) and utilization management (UM) staff.
- Improved Compliance: Ensures adherence to regulations across all lines of business.
- Efficiency and Accuracy: Streamlines authorization and decision workflows, saving time and reducing errors.
- NCQA Level Requirements: Meets stringent quality standards, enhancing the reliability of the service.
Real-World Impact
A testimonial from Ann Donnelly of Priority Health highlights the tangible benefits of GuidingCare, including better data visibility for prior authorizations and more informed decision-making.
