Utilization Management

The UHN/NPP Utilization Management (UM) Program provides clients with opinions about medical necessity for inpatient and outpatient hospital care.  Our UM program combines the expertise of registered nurse reviewers, a board certified medical director and a panel of board certified practicing physicians to help direct patients and providers toward the most cost-effective, quality-driven treatment available.  UM services are offered in our Reno office by licensed nursing staff familiar with the Nevada market and our contracted providers. Our clinical professionals use established national medical guidelines to evaluate necessity for hospitalizations and outpatient services, as well as the appropriateness of the overall treatment plans. 

Case Management

The Case Management (CM) Program provides individuals with access to centers of excellence and specialty care facilities.  Services are designed to improve the quality of patient care while maximizing cost savings by providing timely discharge planning, alternative treatment options, and negotiated rate reductions.  

Case Managers are licensed registered nurses who are advocates, facilitators, and educators, ensuring that members make smooth transitions from inpatient settings to alternate care and home care when appropriate.  Case Managers work with patients and families in tandem with third party administrators (TPAs), insurance companies and reinsurance carriers to provide timely and ongoing information on high-cost cases.

UHN/NPP's integrated UM program provides triggers that automatically refer cases that may benefit from CM intervention by: 

• helping to facilitate early identification
• preventing re-hospitalization
• significantly reducing costs
• educating patients and members to make choices that contribute to a healthier lifestyle

URAC Accreditation

UHN/NPP's partnership with American Health Holding provides Utiliation Review Accreditation Commission (URAC) standards for our Utilization and Case Management programs.  URAC accreditation is a process by which an impartial organization (URAC) reviews a company's operations to ensure the business is conducted in a manner consistent with national standards.  URAC is the largest accrediting body for healthcare.