Smarter Utilization Management. Better Clinical Outcomes.
Effective utilization management requires more than reviewing requests. It requires experienced clinicians, evidence-based decision making, regulatory expertise, and a commitment to delivering timely, consistent determinations that support members, providers, and health plans alike.
TotalMed provides comprehensive Utilization Management (UM) outsourcing solutions that help health plans improve efficiency, manage costs, ensure regulatory compliance, and deliver high-quality member care—whether you need full-service UM, supplemental clinical review support, or additional resources during periods of increased demand.
Comprehensive Utilization Management Services
Our clinical professionals support every stage of the utilization management process while applying your organization’s medical policies, clinical criteria, and regulatory requirements.
Prior Authorization Reviews
Ensure requests for medical services are reviewed efficiently and consistently while supporting timely access to appropriate care.
Concurrent Review
Monitor inpatient and ongoing treatment to promote appropriate levels of care, improve resource utilization, and support positive clinical outcomes.
Retrospective Review
Evaluate services after care has been delivered to ensure medical necessity, policy compliance, and accurate reimbursement.
Appeals and Reconsiderations
Experienced clinical reviewers perform objective first- and second-level appeal reviews with documentation that supports defensible decisions.
Peer-to-Peer Consultation
Facilitate productive conversations between physicians to resolve complex clinical cases, clarify medical necessity, and improve provider satisfaction.
Quality & Documentation Reviews
Identify opportunities to improve documentation, care coordination, and adherence to clinical best practices.
Fraud, Waste & Abuse Support
Provide clinical expertise to identify questionable utilization patterns and support program integrity initiatives.
Clinical Expertise Across Every Specialty
TotalMed’s clinical network includes physicians, nurses, pharmacists, and healthcare professionals across a wide range of specialties, allowing us to match each review with clinicians who understand the unique needs of the case.
Behavioral Health
Cardiology
Oncology
Orthopedics
Neurology
Pediatrics
Women's Health
Gastroenterology
Rheumatology
Pain Management
Internal Medicine
Family Medicine
Pharmacy Services
Surgical Specialties
And many more
Why Partner With TotalMed?
01
Experienced Clinical Professionals
Nurses, physicians, pharmacists, and UM specialists who understand evidence-based clinical decision making.
02
Flexible Outsourcing Solutions
Complete UM outsourcing or additional clinical reviewers during peak periods, tailored to your operational goals.
03
Consistent, Defensible Decisions
We apply your clinical guidelines, medical policies, and benefit plans to ensure every determination is well documented.
04
Regulatory & Accreditation Support
Teams that help you navigate accreditation requirements, regulatory expectations, and quality initiatives.
05
Faster Turnaround Times
Efficient workflows and experienced teams reduce review backlogs while maintaining quality and accuracy.
06
An Extension of Your Team
We work as a seamless extension of your UM department, not an outside vendor.
Built for Today's Health Plans
Our utilization management outsourcing services are designed to support organizations across the healthcare industry, including:
Commercial Health Plans
Medicare Advantage Plans
Managed Medicaid Organizations
Self-Funded Employer Plans
Third-Party Administrators (TPAs)
Provider-Sponsored Health Plans
Integrated Delivery Networks
Accountable Care Organizations (ACOs)
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When Every Clinical Decision Matters, Experience Matters
Partner with TotalMed for utilization management outsourcing that combines clinical expertise, operational efficiency, and consistent, evidence-based reviews that support your members, providers, and organization.