Utilization Management (UM) is a key component of ensuring that injured workers receive appropriate, evidence-based medical care while maintaining cost efficiency for employers and payers. In workers’ compensation, UM is designed to evaluate the necessity, appropriateness, and efficiency of medical services across the continuum of care. This is achieved through three core processes:
A proactive review conducted before treatment is rendered to ensure medical necessity and alignment with evidence-based guidelines.
Ongoing assessment of care during treatment, especially for inpatient stays or complex cases, to support timely, medically appropriate decisions.
A post-treatment evaluation to confirm that services provided were necessary and compliant with medical standards.
Utilization Management is the cornerstone of cost containment—our 100% specialty-based reviews ensure appropriate, cost-effective care for every case, with confidence for payors, providers, and patients alike.
Only Nexus combines tailored workers’ comp utilization management with the gold standard of HITRUST certification—delivering unmatched security, trust, and results. With a clinically driven approach, timely turnaround times, and experienced physician reviewers, we help clients manage costs, improve care quality, and streamline claims processes.