Utilization Management
Plug-and-Play Resources.
Deep Expertise.
Fast Deployment.
If you lack qualified clinical staff to support your medical or behavioral health utilization management (UM) agenda, Toney Healthcare has you covered. Whether you need deep expertise to optimize your operations or staff to support your day-to-day UM activities or build a new line of business, our best-in-class UM experts can help you improve your operational and quality performance.
PLUG-AND-PLAY UM EXECUTION, AVAILABLE NOW.
We offer fast deployment of highly experienced utilization management, quality and compliance resources at all levels—leaders, nurses, medical directors, intake staff and more, all with relevant health plan experience, without the recruiting or hiring burden. Available as a complete unit or as individuals to augment your staff, all we need is training on your system to get us operational and immediately productive, using your tools for full transparency.
We support all medical, behavioral and specialty utilization management functions—prior authorization, member and provider engagement, physician review, appeals and grievances and more—to make you more efficient and help you create a better experience for your members and providers throughout the healthcare journey.
Operational Execution
World-class UM resources
Medical, behavioral health and specialty UM including substance use disorder, ABA management/autism spectrum disorder, MLTSS, IEP, and more
Physician reviewers with extensive experience and multi-state licenses
Appeals and grievances management
Advisory Services
Organizational redesign to remove siloes and improve collaboration across interdisciplinary teams
Quality performance improvement, data analysis and reporting aligned with NCQA, CMS, URAC, and other regulatory requirements
Process optimization and tool alignment to improve efficiency, save costs, and support best practices and compliance
Clinical guidelines integration to right-size care
Personalized training on clinical guidelines, UM best practices, quality and compliance, and more
Medical, Behavioral Health, Specialty UM Experts.
Why Toney Healthcare?
Industry-leading clinical operations with deep best practices expertise
National and regional perspective on UM best practices
Extensive line-of-business UM expertise (Medicare Advantage, Medicaid, SNP, MLTSS, TRICARE, Commercial/ACA, )
Rapid implementation, plug-and-play health management services to ensure speed to value
No recruiting or hiring burden
Medical and behavioral health support
Complete transparency and reporting by working within your system
Full accountability for meeting performance metrics
No burdensome delegation oversight
Nationwide coverage
Platform-agnostic with broad knowledge and experience on all UM platforms
DEEP EXPERTISE TO OPTIMIZE UM PROGRAMS AND PROCESSES
Toney Healthcare offers deep-dive advisory services to streamline administrative complexities and transform your UM operations to deliver timely, right-sized care. Our experts will assess your utilization management operations, including systems, processes, care guidelines and staffing. Then we’ll simplify and automate processes to ensure your business is optimized, your members get timely support, and your clinical resources are working at their highest level.
We’re fluent with national and regional requirements and have extensive line-of-business expertise, including Medicare Advantage, Medicaid, SNP, MLTSS, TRICARE, ACA and commercial.
QUALITY AND COMPLIANCE EXPERTS TO IMPROVE UM PERFORMANCE
Toney Healthcare’s extensive knowledge of standards and best practices covers a range of requirements—CMS, NCQA, URAC, federal, state and more—to support UM benchmarks, accreditation, audits and other quality programs. Plus, we can make sure your policies, processes, systems and reporting are fully aligned with requirements so you stay in compliance.
IMPROVE SATISFACTION AND RATINGS
Our collaborative UM and physician review services can help you reduce friction and expedite decision-making to improve trust and create a better experience for members and providers. The result? Improved outcomes and satisfaction, higher ratings and a more stable provider network.
Sampling of Past Engagements
Rapid deployment of over 100 medical and behavioral UM clinicians for large, growing, multi-state, Medicaid and MLTSS plan
Staff augmentation of appeals and grievances RNs to improve quality and stay in compliance
UM team to eliminate case backlog, bring turnaround times into compliance and deliver best-practices performance
Medical and behavioral physician reviewers deployed nationwide to Medicaid, Commercial and MA plans to provide expertise and close resource gaps
Interim UM and quality leadership
Organizational UM department redesign and process retooling to support compliance, collaboration and medical-behavioral integration
Admissions review including clinical appropriateness of care (observation vs. inpatient status)
Full UM and physician review team (leadership, RNs, intake, medical directors) to provide best in class UM for TRICARE population
UM management, frontline RNs and physician reviewers to support multi-state SNP plan
Development of prior authorization list, guidelines and process