Utilization Management
UM stands for this.
Utilization Management
This person is responsible for conducting oral notifications and inputting data entry requests
Charolette
Day of the week Thanksgiving falls on
Thursday
This person is responsible for Contracting providers and establishing Letter of Agreement's for medically necessary Out of Network requests.
Matt
This review occurs BEFORE services are being rendered
Prior Authorization/Pre-Service
This review is done AFTER services have been provided.
Retrospective Review
This group of people are responsible for non-clinical support, benefit checks, ensuring clinical records are available for processing, and responding to referral inquiries.
Coordinators
This shopping day follows Thanksgiving
Black Friday
This person is responsible for provider relations (office education and outreach)
Tania
This type of check is needed when a request for an OON provider is going to be approved.
Hint: done by credentialing.
Sanction Check
This referral status means the requested services meets applicable guidelines.
Approved
This person provides staff education, monitors daily compliance, and outreach to the team to ensure the department is within turnaround time
Janette
This orange fruit is commonly carved out for Halloween and also used in popular pie served at Thanksgiving
Pumpkin
This nurse manages patients who are admitted at out of network facilities.
Hint: she used to be part of our UM team
Nakaia
This third-party evaluator is used to determine if a high-cost DME is medically necessary
Periscope
This turnaround time is 24 hours from date and time of receipt.
Pharmacy (Part B) Urgent
This person is responsible for appeal triage, transplant reviews, and decision letter writing
Vianna
This famous cartoon dog celebrates Thanksgiving with Charlie Brown
Snoopy
VP of Value Based Care
Yumi
This person is who the nurse sends referral reviews to when it cannot be approved or requires higher level review.
Medical Director
Names of all the Health Plans managed by UM.
Aetna
Anthem Blue Cross
Blue Shield
Cigna
Health Net
Humana
UHC
SCAN
This person manages 2 utilization management departments & also a workers compensation department.
Jeff
True or False: we have Thanksgiving off
True
This person shares the same first name with 2 other people in Care Coordination
Michelle
This line of business does not observe Holidays
CMS/Medicare