Clinical Management

We provide clinical management support for the administration of health care services, ultimately improving patient outcomes. With particular emphasis on Medicaid members and other vulnerable populations, our clinicians develop new service delivery and financing models, which recognize a greater reliance on home- and community-based care for Medicaid enrollees, rather than institutionalized care.

We offer:

  • Clinical guideline development for new prescription drugs, medical procedures, and dental procedures
  • Utilization management including prior authorization of services, retrospective review, concurrent review, utilization review, and level of care determinations
  • Program integrity and fraud prevention including financial audits, recoveries, program quality reviews  and quality improvement plans
  • Policy development and management support for Medicaid program staff to optimize program policy and regulate decision making
  • Provider network administration including provider recruitment, enrollment and training, program integrity audits, and quality improvement plans
  • Complex member care consultation to support other contracted care coordination organizations (managed care or accountable care organizations) and assist them with care delivery challenges
  • Reporting, data analysis and data handling including the provision of routine and recurring spending utilization and trend reports to Medicaid executives, senior management, and program staff
  • Quality management design, development and evaluation