Utilization Management

Overviews
Written By Guest User

Plug-and-Play Resources.
Deep Expertise.
Fast Deployment.

If you lack qualified clinical staff to support your medical or behavioral health utilization management (UM) agenda, Toney Healthcare has you covered. Whether you need deep expertise to optimize your operations or staff to support your day-to-day UM activities or build a new line of business, our best-in-class UM experts can help you improve your operational and quality performance.

PLUG-AND-PLAY UM EXECUTION, AVAILABLE NOW.

We offer fast deployment of highly experienced utilization management, quality and compliance resources at all levels—leaders, nurses, medical directors, intake staff and more, all with relevant health plan experience, without the recruiting or hiring burden. Available as a complete unit or as individuals to augment your staff, all we need is training on your system to get us operational and immediately productive, using your tools for full transparency.

We support all medical, behavioral and specialty utilization management functions—prior authorization, member and provider engagement, physician review, appeals and grievances and more—to make you more efficient and help you create a better experience for your members and providers throughout the healthcare journey.

 
 

Operational Execution

  • World-class UM resources

  • Medical, behavioral health and specialty UM including substance use disorder, ABA management/autism spectrum disorder, MLTSS, IEP, and more

  • Physician reviewers with extensive experience and multi-state licenses

  • Appeals and grievances management

Advisory Services

  • Organizational redesign to remove siloes and improve collaboration across interdisciplinary teams

  • Quality performance improvement, data analysis and reporting aligned with NCQA, CMS, URAC, and other regulatory requirements

  • Process optimization and tool alignment to improve efficiency, save costs, and support best practices and compliance

  • Clinical guidelines integration to right-size care

  • Personalized training on clinical guidelines, UM best practices, quality and compliance, and more

Medical, Behavioral Health, Specialty UM Experts.

Why Toney Healthcare?

  • Industry-leading clinical operations with deep best practices expertise

  • National and regional perspective on UM best practices

  • Extensive line-of-business UM expertise (Medicare Advantage, Medicaid, SNP, MLTSS, TRICARE, Commercial/ACA, )

  • Rapid implementation, plug-and-play health management services to ensure speed to value

  • No recruiting or hiring burden

  • Medical and behavioral health support

  • Complete transparency and reporting by working within your system

  • Full accountability for meeting performance metrics

  • No burdensome delegation oversight

  • Nationwide coverage

  • Platform-agnostic with broad knowledge and experience on all UM platforms

DEEP EXPERTISE TO OPTIMIZE UM PROGRAMS AND PROCESSES

Toney Healthcare offers deep-dive advisory services to streamline administrative complexities and transform your UM operations to deliver timely, right-sized care. Our experts will assess your utilization management operations, including systems, processes, care guidelines and staffing. Then we’ll simplify and automate processes to ensure your business is optimized, your members get timely support, and your clinical resources are working at their highest level.

We’re fluent with national and regional requirements and have extensive line-of-business expertise, including Medicare Advantage, Medicaid, SNP, MLTSS, TRICARE, ACA and commercial.

QUALITY AND COMPLIANCE EXPERTS TO IMPROVE UM PERFORMANCE

Toney Healthcare’s extensive knowledge of standards and best practices covers a range of requirements—CMS, NCQA, URAC, federal, state and more—to support UM benchmarks, accreditation, audits and other quality programs. Plus, we can make sure your policies, processes, systems and reporting are fully aligned with requirements so you stay in compliance.

IMPROVE SATISFACTION AND RATINGS
Our collaborative UM and physician review services can help you reduce friction and expedite decision-making to improve trust and create a better experience for members and providers. The result? Improved outcomes and satisfaction, higher ratings and a more stable provider network.

Sampling of Past Engagements

  • Rapid deployment of over 100 medical and behavioral UM clinicians for large, growing, multi-state, Medicaid and MLTSS plan

  • Staff augmentation of appeals and grievances RNs to improve quality and stay in compliance

  • UM team to eliminate case backlog, bring turnaround times into compliance and deliver best-practices performance

  • Medical and behavioral physician reviewers deployed nationwide to Medicaid, Commercial and MA plans to provide expertise and close resource gaps

  • Interim UM and quality leadership

  • Organizational UM department redesign and process retooling to support compliance, collaboration and medical-behavioral integration

  • Admissions review including clinical appropriateness of care (observation vs. inpatient status)

  • Full UM and physician review team (leadership, RNs, intake, medical directors) to provide best in class UM for TRICARE population

  • UM management, frontline RNs and physician reviewers to support multi-state SNP plan

  • Development of prior authorization list, guidelines and process

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