Utilization Management

Our Utilization Management team ensures the medical necessity, appropriateness and efficiency of the use of services under the provisions of our customers' health benefits plans. A key feature is the pre-certification process. Working with members before they receive care and while they receive care, we see to it that they get the right care at the right time.

At Prairie States, the nurses performing these vital tasks are in-house, working side by side with our claims processing staff. Our seamless integration, rare in the industry, gives us the most efficient means of reducing costs as there is no time or information lost in a hand-off to an outside entity.

Our Utilization Management nurses, supported by a full panel of physician specialists, review all inpatient and outpatient services received to: ensure doctors' orders are carried out in an efficient and accurate manner, identify questionable medications or procedures, plan ahead and monitor the member's progress. By working closely with healthcare providers, we give members information and options that can reduce hospital stays and speed recovery.

We are proud members of these respected organizations: