The GuidingCare Solution Suite
GuidingCare Utilization Management
Seamless Authorizations, Better Outcomes
Streamline your workflows and improve care delivery with GuidingCare® Utilization Management. Designed for maximum efficiency and adaptability, this powerful module supports every stage of the authorization lifecycle, enabling your team to focus on delivering better outcomes for members while reducing operational complexity.
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GuidingCare Achieves AA Certification for HEDIS Measures Subset
GuidingCare Platform & Mobile Clinician App Earn CA Veracode Verified Status
GuidingCare Achieves NCQA Population Health Management Prevalidation
GuidingCare Platform Achieves HITRUST Certification
Features of Our Utilization Management Solution
Comprehensive Workflows
Optimize the entire utilization management process with clinically sound, automated workflows. From Peer Reviews to MD and Concurrent Reviews, tasks are streamlined to minimize effort and maximize accuracy.
Evidence-Based Decision Making
Leverage seamless integration with MCG Cite AutoAuth and InterQual Connect™ for automated decision-making supported by evidence-based guidelines. This ensures compliance while reducing review workloads.
Integration Across the Ecosystem
The GuidingCare Utilization Management module seamlessly connects with your existing systems, creating a unified ecosystem where all stakeholders can monitor authorizations, track progress, and access real-time data for informed decisions.
Clinical Guidelines
Integration between MCG Cite AutoAuth and InterQual Connect support automated decision-making and extensive integration with MCG and InterQual provides users direct access to evidence-based clinical guidelines, so review details are saved against each request, supporting the decision process.
Integrated Platform
Seamlessly integrates with the GuidingCare solution suite, allowing stakeholders to track appeals, enrollment, encounters, and care planning progress.
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See how your team can benefit from a utilization management solution with a single, comprehensive care record and streamlined authorization and decision workflows.
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FAQ
What is utilization management software?
Utilization management software helps health plans to manage members’ utilization of benefits solution. This type of software streamlines the utilization review process by automating business workflows, enabling seamless access to evidence-based clinical guidelines, and supporting custom configurations that adjust to your organization’s specific needs. Utilization Management software supports the authorization lifecycle from request and review to status determination to correspondence with members and providers with helpful clinical guidelines and configurable authorization management workflows help you manage utilization effectively.
What are the 3 assessments for utilization management?
There are 3 types of assessments in Utilization Management (UM) to review medical necessity: prospective, concurrent, and retrospective. Per CMS, medical necessity is “services or supplies that: are proper and needed for the diagnosis or treatment of a medical condition, are provided for the diagnosis, direct care, and treatment of a medical condition, meet the standards of good medical practice in the local area, and aren’t mainly for the convenience of the patient or doctor." -A prospective review looks at whether the services or scheduled procedures are medically necessary prior to admission. -Concurrent reviews look at whether services or procedures are medically necessary during the time in which a patient/member is in an acute (e.g. a hospital) or post-acute setting (e.g. an outpatient clinic) -Finally, retrospective reviews determine whether procedures or services are medically necessary after the treatment.
What is the difference between utilization review and utilization management?
Utilization review is the process used to determine whether medical services for patients are being used appropriately (right care, right provider, right setting). Utilization management is the strategy or approach taken based on the utilization review data to improve patient outcomes, manage operations and costs, and ensure optimal utilization for staff and resources.
HealthEdge Care-Payer Integration
HealthRules Payer is even more powerful when combined with GuidingCare®. Our unique Care-Payer Data Exchange solution provides the API-based integration that enables the continuous management of member care and core administrative processes.
Care-Payer provides a range of vital capabilities, including:
- Standardized core data delivery from HealthRules Payer to GuidingCare
- Authorization entry workflow improvement, including single-case agreement and referral category enhancement
- Near-real-time authorization delivery from GuidingCare to HealthRules Payer
Most notably, Care-Payer includes Benefit Predictor integration. This unique feature enables GuidingCare users to quickly and easily answer complex benefit questions prospectively from members and providers.
This Benefit Predictor integration is incorporated into several key workflows, giving Utilization Management staff and care managers unparalleled access to near-real-time benefits information.
Care-Payer Data Exchange delivers significant benefits to your organization, including:
- Smooth implementation through HealthEdge expertise and standardized processes
- Synchronized data sets between HealthRules Payer and GuidingCare
- New levels of operational efficiency in authorization entry and medical management
- Improved payment integrity
- Certified data exchange
HealthEdge Care-Wellframe Integration
HealthEdge Care-Wellframe is a scalable, flexible integration that brings together Wellframe and GuidingCare, our full-spectrum care management platform, into one unified solution that offers health plans a comprehensive package with the right tools to transform their care management function.
The Care-Wellframe integration enables health plans to:
- Streamline Care Management Workflows: A fully integrated solution provides care managers with a comprehensive member view through a singular care management platform – no more swivel chair.
- Enhance Member Engagement: Meet members where they are on their own terms through omnichannel communication and a multi-modal digital front door.
- Scale Care Management Resources: Maximize care manager efficiency and support more members with dynamic decision support tools, alerting logic, and instant access to clinical and community SDOH resources.
With Care-Wellframe, health plans unlock the power to revolutionize care management operations and elevate member outcomes through a seamless, unified solution designed for impact and scalability.
LEARN MOREExplore the GuidingCare Solution Suite
GuidingCare®
Comprehensive, Configurable, Connected
GuidingCare offers a comprehensive suite of modules tailored to meet the evolving needs of healthcare payers and providers. Designed to operate seamlessly within your existing ecosystem, our solutions ensure interoperability, adaptability, and future-proofed capabilities for today's evolving care environments.
Learn MoreGuidingCare Care Management
Effectively operationalize an evidence-based, person-centered care strategy with workflows that align with NCQA standards, CMS guidelines, and personalized care requirements. Enhance operational efficiency while enabling care teams to identify gaps and take targeted actions.
LEARN MOREGuidingCare Utilization Management
Simplify and optimize the complete authorization lifecycle with advanced tools that integrate clinical guidelines, predictive modeling, and AI-driven workflows to boost productivity and reduce administrative bottlenecks.
LEARN MOREGuidingCare Authorization Portal
Streamline provider interactions with an intuitive tool for preauthorization, messaging, and appeals. Empower providers and staff with an interface designed for clarity and simplicity while ensuring alignment with compliance standards.
Learn MoreGuidingCare Appeals & Grievances
Streamline the appeals and grievances process to meet regulatory demands with automated workflows, task tracking, and correspondence. Configurable tools ensure compliance and timely resolutions for all grievance types.
Learn MoreGuidingCare Business Intelligence
Make smarter decisions with over 50 standard reports and an actionable analytics suite. Uncover trends, build ad hoc reports, and transform data into strategic insights.
Learn MoreGuidingCare Population Health
Leverage advanced gaps-in-care analytics to identify high-risk members, prioritize interventions, and optimize health outcomes. Empower care teams with SDOH and analytics to address risk factors and inequities for more effective care.
Learn MoreAdvanced Tools for Transformation
GuidingCare University
Empower your team with our self-service digital training platform offering on-demand, video-based learning to optimize user interaction with the GuidingCare Solution Suite.
LEARN MOREGuidingCare Rules Designer
Independently create, manage, and deploy business rules into your GuidingCare instances to automate workflows and decision-making.
LEARN MOREGuidingCare Pediatric Population Health Management
Standard and enhanced tracking and reporting to meet federal Early and Periodic Screening, Diagnostic and Treatment (EPSDT) requirements in Medicaid.
LEARN MOREGuidingSigns® Analytics
A clinical decision support system that transforms data into actionable insights for healthcare payers and providers.
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