Care and Utilization Management Experience

Our personnel have extensive experience in providing consulting, data analysis and clinical services for utilization review/case management in both Medicaid and commercial fee for service and managed care programs. We provide the services of licensed pharmacists and professional staff with extensive experience in clinical and economic evaluations to meet the requirements of the contract. We also provide evaluation and assessment regarding the quality of care participants receive as a result of drug therapies based on treatment guidelines and best practices and other clinical intervention and educational support provided for enhancing clinical outcomes.

Utilization Review and Case Management Activities

  • Sample size and study population evaluations
  • Enhanced risk assessment and stratification using predictive cost modeling to determine increased cost of uncoordinated care
  • Uncoordinated care claims analysis using proprietary criteria driven algorithms
  • Statistical comparison methods
  • Age and demographic group selection and measures
  • Disease assignment and classification instruments
  • Health quality assessment tool evaluation and use
  • Outcome and data measures selection
  • Selection of study instruments
  • Study exclusion criteria
  • Study design and cost and quality evaluation methods
  • Intervention design and evaluation

Summary of Analytical Findings and Identified Savings for State Medicaid Programs