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Utilization Management & Medical Necessity Review:
- Performing physician-level utilization management reviews for behavioral health services across all applicable levels of care
- Rendering medical necessity determinations using Company-approved, evidence-based criteria
- Reviewing escalated, complex, and reconsideration cases
Peer-to-Peer & Provider Engagement:
- Conducting peer-to-peer consultations with treating psychiatrists and other behavioral health providers
- Communicating clear, clinically sound rationales for utilization management decisions
- Supporting resolution of provider disputes related to medical necessity
Accreditation & Quality Support:
- Performing utilization management activities in alignment with NCQA Health Plan Accreditation standards
- Supporting readiness for NCQA surveys, audits, and corrective actions related to behavioral health utilization management
- Assisting with the development, review, or refinement of utilization management policies and procedures
Guidehealth
Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence. They aim to make healthcare affordable, improve patient health, and restore fulfillment in practicing medicine for providers. Driven by empathy and AI, they leverage remotely-embedded Healthguides™ and a centralized Managed Service Organization.