Problem to Solve
Despite the criticism they receive from patients, their advocates and providers, utilization managers are often the unsung heroes of health care services, enabling organizations to contain costs, maintain quality and reduce unnecessary and inefficient care. In fact, in an increasingly dynamic, value-based care market, effectively managing health care services and costs can make the difference to an organization’s profitability – or even its survivability.
Unfortunately, the utilization management (UM) department of a major health care system was in flux and disarray, just as its work needed to grow to meet the needs of more than 5,000 network physicians and their patients. The UM department faced multiple operational and process deficiencies, due in part to key staff member departures that had left it unable to keep pace with internal demand. New staff additions lacked the experience and training to deliver significant value. Questions were arising regarding the department’s ability to meet the requirements of a new joint venture contract between the health care system and a major national health insurer.
Rather than operating at sub-optimal productivity and potentially failing to achieve its crucial joint venture-related role, the UM department engaged Freed Associates (Freed) for two principal tasks:
Strategy and Tactics
As Freed immediately began fulfilling the vacant UM program manager role, it also identified multiple long-term strategic opportunities for operational and process improvements for the department, including:
Simultaneously, Freed also began assisting the UM department with supporting its joint venture-related needs, based on existing UM quality measurements. The primary tasks for this role, which involved transforming UM-related clinical activities to support the new joint venture, included:
The client, with Freed’s assistance, successfully completed all identified tasks to improve the UM department’s operations and fulfill its clinical responsibilities associated with the health care system’s new joint venture contract. Results highlights included:
To support the health system’s new joint venture contract, UM staff, in collaboration with Freed and all relevant clinical departments, created new workflows, meeting templates and IS support guidance. Lastly, Freed temporarily fulfilled the UM program manager role while this position was vacant, then assisted the staff member hired for this role with onboarding and integrating into the position.
Managing a high-performing UM department is challenging enough given the inherent and constant demands of typical UM functions.
By addressing its operational and process needs, the UM department enhanced its overall efficiency and productivity. This work proved vital and timely as the department simultaneously fulfilled all of the clinical transformation-related components of an important new joint venture agreement between the health care system and a major national health insurer. The net result to the health care system is a much higher-performing and more effective UM department.
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