First Choice Health Home : Medical Management : Utilization Management

First Choice Health’s Utilization Management Program is a core Medical Management service that is designed to promote the delivery of evidence-based and appropriate care to enrollees. Components of the program include:

• Pre-certification: generally focuses on all elective inpatient admissions and targeted outpatient services.
• Inpatient Concurrent Review & Discharge Coordination: incorporates daily clinical rounds by a FCH Medical Director and the clinical team to identify potential gaps in care, evaluate the appropriateness of care, and assist in transition planning. Collegial calls are made by the Medical Director to the attending physician to resolve potential care gaps.
• Outpatient Gap Interventions: is a unique program that uses available claims and pharmacy data to identify and evaluate enrollees with diagnoses and care patterns that are likely to adversely impact the employee's health and workplace productivity.

Our registered nurses follow each client’s summary plan document and utilize evidence-based guidelines to inform appropriateness of services. Where appropriate, care is coordinated with FCH Case Management services.