Health Utilization Management
URAC’s accreditation program assures the clinical and operational soundness of the UM process by evaluating it against nationally recognized standards.
Patients with major medical diagnoses often struggle to understand complex care coordination, managing multiple care providers, and knowing what to do next. Patients can take better control of their care and the associated costs when they collaborate with the Zelis medical management team to enrich their healthcare experience.
Participating Zelis Open Access Pricing medical management members with high-cost and specialty cases are connected to an experienced Registered Nurse Certified Case Manager who will help review plan benefits, track results, coordinate care, and advocate for them throughout their treatment journey.
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Our URAC-accredited utilization management program provides pre-certification and concurrent review requests for medical services. By utilizing evidence-based standard of care guidelines, services are ensured to be clinically appropriate, administered by proven methods, provided by appropriate healthcare providers, and delivered in the appropriate clinical setting. Â
We deliver:Â
Our URAC-accredited case management program delivers care coordination to members with the highest needs who have chronic, complex, or catastrophic conditions and/or treatment needs including oncology, end stage renal, organ transplantation, clinical trial, gene therapy, hemophilia, autoimmune, high-risk maternity, birth anomaly, and other rare and complex medical conditions. Case management RN clinical experts support members in achieving optimal clinical outcomes along the continuum of care utilizing evidence-based national standards.Â
We achieve program outcomes by:Â
Disease management is integrated within our URAC-accredited case management program to deliver chronic condition management to members with combined chronic condition diagnosis including asthma, Chronic Obstructive Pulmonary Disease, diabetes, heart failure, coronary artery disease or hypertension.Â
We impact care by:Â
The medical management clinical team aims to provide a seamless transition to the new benefits plan for members who are who are receiving medical treatments that require precertification by the medical benefit plan and to address any concerns regarding potential disruption of recurring medical care. To ensure a seamless transition, members and clients should complete these forms.
Access Forms LibraryURAC is the independent leader in promoting healthcare quality through accreditation, certification, and measurement. By achieving this status, our organization* has demonstrated a comprehensive commitment to quality care, improved processes, and better patient outcomes.
The URAC accreditation process demonstrates a commitment to quality services and serves as a framework to improve business processes through benchmarking organizations against nationally recognized standards.
*Innovative Medical Risk Management, Inc. d/b/a CareValent d/b/a Payer Compass, a wholly owned subsidiary of Zelis Healthcare, LLC, provides medical management services as a URAC accredited organization.
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