Utilization Review Services
Take control of rising injury costs and regulatory compliance challenges with Conduent’s utilization review services and clinical peer review services.
Utilization Review Services and Peer Review Services
With today’s unrelenting focus on quality patient outcomes and rising medical costs, having an effective utilization management program in place is more important than ever for effective claims management.
Conduent has been providing cost-effective utilization management services for casualty insurers and self-funded employers for over 30 years, helping to improve patient care and claims outcomes while lowering medical and indemnity costs.
Our clinical experts, supported by our care management platform, consistently deliver defensible, evidence-based recommendations to ensure claimants receive appropriate care in the most appropriate setting, as proven by our less than 2% appeal rate.
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Less than 2% of cases appealed
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Reviewers active in over 40 medical specialties
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Quality assurance review on 100% of cases
Utilization Review Services
Utilization review improves quality of care and accelerates patient recovery while curbing unnecessary medical treatment. Conduent’s mission is to leverage nationally recognized guidelines to ensure compliance and provide timely recommendations to our clients concerning the appropriateness of the care.
All Conduent UR services are conducted in strict accordance with state-mandated guidelines and URAC-approved protocols and delivered by our in-house team of licensed and registered nurses under the clinical direction of our national medical director.
Services
- Prospective (preauthorization), concurrent, and retrospective reviews
- Pharmacy utilization review
- Nationwide capabilities with licensures in appropriate jurisdictions, as well as strategic UR for states without jurisdictional guidelines
- Evidence-based national guidelines or state-specific guidelines
- UR platform integrated with case management and bill review
- All UR nurses are Conduent employees
- Internal appeals and resolution dispute process
- URAC accredited for Workers’ Compensation Utilization Management since 2006
Clinical Peer Review Services
A clinical or medical peer review involves a comprehensive review of a patient’s medical records by a physician, who provides an objective opinion based on the facts provided in the records. Requests for in-depth evaluations of medical necessity, appropriateness of care, causality and relatedness are conducted by Conduent’s panel of physician reviewers.
Each of Conduent’s physician reviewers are URAC accredited and licensed in their area of specialty. Our panel includes more than 40 medical specialties, including occupational medicine, orthopedics, pain management, and neurology.
Our specialty-matched clinical peer review services involve an extensive review of the requester’s questions, associated medical records, and case-related information. Special focus is given to pre-existing conditions, compensability, causality, and other relevant factors. A quality assurance review is conducted on 100% of peer reviews.
Services
- Peer-to-peer discussions
- Causality determinations
- Initial certifications and appeal certifications
- Complex medical records file reviews
- Impairment ratings
- Clinical, disability, and return-to-work consultations