Utilization management | EXL

All, some, or just a little

With a flexible approach, you don’t have to settle for a blanket offering. Our utilization management (UM) program gives you options that fit your budget, while driving efficiency. Our deep pool of experts remove barriers from complex medical, behavioral, and pharmacy UM operations, allowing our clients to focus on more critical areas, like their patients and members.

Time to separate

In today’s healthcare landscape, clinical and non-clinical teams spend 30-40% of their time on administrative tasks, including working in multiple systems with multiple views, with exorbitant amounts of data and manual lookup. Enter EXL Health UM operations. With a variety of best-in-class technologies and a proven system that gets results, we take UM workflows where others don’t.

Proven outcomes

96%

reduction in pre-certification case handling time

15%

Improvement in document efficienc

3

of the 4 top-tier health plans use our UM services

Improved

member and provider experiences and satisfaction

Improved

operational and administrative cost

Improved

consistency, accuracy and efficiency

Our model

Through end-to-end Utilization Management services and solutions, our team of UM experts take the heavy lifting of complex medical, behavioral and pharmacy UM operations off of our clients’ shoulders and allows them to focus on more critical areas of their performance.

Our teams of nurses, physicians, behavioral experts and non-clinicians can manage some, or all of the authorization lifecycle using a unique combination of technology, analytics, data and domain expertise, customized to meet client requirements.

Our model is highly flexible and can include fully or partially delegated services, capacity services, or standalone technology, analytics and/or automation.

Our solutions

Evolving solutions for evolving needs

End-to-end services

End-to-end services

<p>We deliver end-to-end UM services across the medical, behavioral and pharmacy industries. Delivered using proven clinical guidelines, we cover the full pre-authorization lifecycle.</p><ul style="margin-top:0in;" type="disc"><li style="tab-stops:list .5in;">Pre-authorization<o:p></o:p></li><li style="tab-stops:list .5in;">Concurrent review<o:p></o:p></li><li style="tab-stops:list .5in;">Post-service clinical claims review<o:p></o:p></li><li style="tab-stops:list .5in;">Peer-to-peer consultation<o:p></o:p></li><li style="tab-stops:list .5in;">Network steerage<o:p></o:p></li><li style="tab-stops:list .5in;">Repatriation<o:p></o:p></li><li style="tab-stops:list .5in;">Benefits and eligibility<o:p></o:p></li><li style="tab-stops:list .5in;">Program referrals<o:p></o:p></li><li style="tab-stops:list .5in;">Appeals and grievances<o:p></o:p></li></ul>

Integrated analytics & insights

Integrated analytics & insights

<p>Advanced data and analytics infuse into our UM solution to enable more intelligent and efficient operations and workflows. Our data and analytic capabilities provide insights into opportunities to improve core UM program design and allows health plans to drive program enhancements and greater efficiencies, including:</p><ul><li>Ensuring UM programs are focused on the right pre-authorizations</li><li>Establishing providers as gold card status</li><li>Identifying provider coverage to ensure network adequacy</li></ul>

Digital & automation

Digital & automation

<p>We take UM to the next level by enabling our operations with a variety of digital technologies, including machine learning, artificial intelligence, natural language processing, and population health in order to drive efficiencies and accuracies across operations, and:</p><ul><li>Eliminate highly manual and time consuming intake and authorization tasks</li><li>Meet and exceed required turnaround times</li><li>Standardize clinical decision making</li><li>Improve accuracy and efficiency</li></ul>

CareRadius:care management & population analytics platform

CareRadius:care management & population analytics platform

<p>Our analytics enabled and integrated care management platform provides health plans and providers efficient, compliant, and automated case management and utilization management<br>workflows.</p><p>The platform facilitates a whole-person health approach and delivers<br>a holistic view of the clinical, behavioral, and social determinants of a member or patient in order to support improved clinical and financial outcomes. CareRadius™ is highly flexible and configurable and provides:</p><ul><li>Efficient, analytics enabled workflows</li><li>Flexible and compliant operations</li><li>Smarter stakeholder collaboration and engagement</li><li>Nearly endless data and integration possibilities</li><li>Robust out-of-the box and custom reporting</li></ul>

Compliance & accreditation

Compliance & accreditation

<p>We maintain robust and comprehensive processes, policies, and procedures to support compliance with all regulatory guidelines. We’re URAC accredited for health utilization management and NCQA accredited for case & utilization management. Our U.S. based teams maintain utilization review licensure for over 22 U.S. states with the ability to apply for more as needed.</p>

Insights

Explore the latest perspectives

Beyond traditional UM: Embracing the power of advanced t...

View Case study

CareRadius™

View Infographic

A Leader and Star Performer in 2022 Everest PEAK Matrix®...

View Reports & research

View all insights