A payer needs to implement a program to address the rising healthcare expenses and ensure...

Step 1: Requirement Analysis

Payer needs to manage healthcare expenses while ensuring quality, affordable care.

Seeks to streamline approval processes for care requests.

Step 2: Utilization Management in Health Cloud

Utilization Management (UM) provides workflows and automation for reviewing, approving, or denying care requests. This supports balancing cost controls with quality care through evidence-based review processes.

Extract:

“Utilization Management helps payers manage costs and ensure members receive appropriate care by streamlining the review and approval process for pre-authorizations and care requests.”

Administer Health Cloud – Utilization Management

Step 3: Review of Options

A. Utilization Management: Directly addresses care request review, cost, and quality balance.

B. Provider Network Management: Focuses on managing provider networks, not utilization/cost review.

C. Intelligent Appointment Management: For scheduling only.

D. Integrated Care Management: Focuses on care coordination, not cost/approval workflow.