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Utilization ManagerAddressing the medical costs of a claim requires knowledge, experience and the ability to effectively communicate and negotiate with healthcare providers.The goal of utilization management is to align reasonable and necessary treatment with claim expenditure.

We offer a full spectrum of utilization management products to include:

  •  Pre-Certification, Concurrent and Retrospective Review

    Procura case managers utilize valid clinical criteria to determine appropriate treatment, level of service and duration of care. The program is physician supported to assure quality and accuracy of our clinical recommendations.

    The program offers pre-certification which is monitoring care for effectiveness during the delivery phase and retrospective, or after treatment has concluded.

  •  Auditing Services

    Select cases may require the detailed review of a provider bill to medical records. Procura offers this service as an onsite option, traveling to and meeting with the provider office to review charges to documented care. In addition, Procura offers the option of desk audit in which we will secure medical records for a comprehensive review of itemized charges.

  •  Utilization Review

    Utilization review is an integral component to the Procura medical management services, whether it be field or telephonic services. We also offer utilization services as an unbundled program to meet the needs of our client base. We provide the necessary clinical information to empower adjusters to make informed decisions regarding the medical treatment and simultaneously, assure adherence to the state specific regulations. Procura is certified as a Utilization Review Organization in the State of Pennsylvania and holds additional state certifications to serve our clients.

  •  Peer Review

    Procura offers this service by utilizing credential providers who possess the same specialty of the provider under review. Comprehensive reports are secured for claim decision support. Procura is a certified Act 6 (Pennsylvania) Peer Review Organization.
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