Overview

Our CARE Programs for utilization management establish appropriate processes for reviewing the medical necessity of inpatient and outpatient services, as well as supplemental and alternative health care services. And our case management services help ensure delivery of timely, appropriate, and cost-effective health care services for catastrophically ill and injured patients. OptumHealth CARE Programs for utilization review and case management are accredited by the URAC.

Utilization and Case Management Services

Our utilization management provides a comprehensive, systematic, ongoing review of clinical care and services utilization — including inpatient and outpatient services from hospitals, physicians, and secondary providers. We work directly with internal and external client care management processes to evaluate coordination of care, identify under-and over-utilization, and coordinate appropriate care management.

Our case management services begin with a comprehensive patient assessment, followed by a comprehensive care plan developed in collaboration with the patient and family, the treatment team, and the client. As the care plan is implemented, we ensure patient progress through ongoing monitoring and re-evaluation. When problems are identified, we adjust the care plan to support the optimal outcome for patient and family while controlling costs for the client.