Utilization Review

CALL TODAY!

877-366-0611

Chicago, Illinois Utilization Review Services

Our Utilization Review Services support the right care at the right time in the right place. All our utilization review nurses are registered nurses (RNs), and CCM or ACM certified. All hold a Bachelor of Science in Nursing (BSN), and most hold Master degrees. Our nurses have acute care experience as well as clinical experience in a variety of health care settings.

We provide Utilization Review Services for the following providers:

  • Medicare & Medicaid Services (CMS)
  • Hospitals
  • Insurance Companies
  • Physician Offices
  • Outpatient Clinics/Surgery
  • Nursing Homes
  • Acute Rehabs/Long Term Acute Care
  • Home Care Agencies

Types of Utilization Review:

  • Prospective
  • Concurrent
  • Retrospective

We Provide Three Types of Reviews:

1. Prospective review is review or authorization for elective procedures or services prior to such services being rendered.

2. Concurrent review is review or authorization for procedures or services during the time such services are being rendered. An example of concurrent review is when a physician calls a Managed Care Organziation (MCO) and requests an initial length of stay (LOS) for a patient and then after the patient has been admitted into the hospital, the physician calls the MCO and explains that due to extenuating circumstances the patient needs to stay in the hospital for a longer time and the physician requests an extended length of stay (ELOS).

3. Retrospective review is review of services after they have been rendered, typically using medical charts.

Spectrum Utilization review (UR) nurses are seasoned and experienced, they work for you to maximize the quality and cost efficiency of health care services. Through regular reviews and audits, we ensure that patients receive the care they need without burdening the health care system with unnecessary procedures, ineffective treatments or overlong hospital stays. Our Utilization review nurses also help insureds to make informed decisions about their health care by educating them on the benefits and limitations of their Medicare, Medicaid or private health care coverage.

Our reviewers are an experienced nurses who uniquely suited for utilization reviews due to their extensive knowledge of patient care, medical treatments and hospital procedures. They rely on their clinical judgment, honed over years in acute care settings, to make responsible decisions that promote patient health and well-being while keeping resources available to those most in need.

Our UR nurses advise insurance companies and health care facilities on questions of hospital admission, length of stay, imaging studies, surgeries, medications, referrals and many other treatments and procedures. To formulate these recommendations, our UR nurses review medical records, talk to patients and providers and conduct additional research as needed. Also, our UR nurses follow strict protocols to determine whether patients meet the standards for insurance reimbursement. They also pre-certify people for medically necessary procedures and hospitalizations, and at times, travel to visit with patients and providers.

Our UR nurses work in hospitals, nursing homes and clinical settings where we manage patient care through daily case reviews and create discharge plans that help patients transition smoothly and safely to their homes or other facilities. Our nurses have a significant amount of patient and family contact, as we must often explain the rationale behind our recommendations. We also work closely with insurance companies to ensure that the provider will be reimbursed for services rendered.

Qualifications

All our utilization review nurses are CCM or ACM certified, are registered nurses (RNs), all hold a Bachelor of Science in Nursing (BSN), and most hold Master degrees. Our nurses have acute care experience as well as clinical experience in a variety of health care settings. This allows us to develop the clinical judgment necessary to manage patient care in a safe and effective manner.

Our UR nurses are team players who work closely with physicians, nurses, health care providers, patients, family members and insurance company personnel. We have excellent communication and interpersonal skills.