The Utilization Review & Status Manager unifies payer status tracking, clinical criteria assessments, and timing visibility into a single operational dashboard. It allows review nurses, case managers, and revenue integrity staff to monitor inpatient and observation determinations in real time, anchored in InterQual or MCG guidelines and aligned with CMS’s Two-Midnight Rule.
By linking clock tracking, documentation, and criteria outcomes in one place, the tool provides a defensible, data-driven foundation for concurrent review, peer-to-peer support, and appeals preparation. Automatic timers and alerts help teams act before status clocks expire, while structured exports streamline the handoff to compliance, billing, and payer correspondence workflows.
Benefits
- Fewer denials: Supports timely, defensible determinations by surfacing criteria and payer status side-by-side with encounter data.
- Faster decisions: Provides at-a-glance clock tracking, clinical justification fields, and auto-nudges before review windows close.
- Audit-ready documentation: Maintains complete records of criteria findings, status changes, and appeal history in one place.
- Improved collaboration: Enables UR nurses, physicians, and revenue integrity teams to align quickly on status decisions using shared dashboards.
Key Capabilities
- Status and clock tracking for inpatient/observation determinations, with automatic timer resets and alerts.
- Integrated criteria capture links for InterQual/MCG documentation or external review attachments.
- Two-Midnight rule alignment with clear indicators for expected vs. actual stay duration.
- Appeal packet generation with summary, timeline, and attached evidence for payer submission.
- Audit trail and role-based visibility showing who performed each review, when, and what decision was made.
- Dashboard analytics for denial trends, timing compliance, and status change distributions.
Great for
- Utilization Review Nurses and Case Managers: Track inpatient and observation status with InterQual/MCG alignment, payer feedback, and Two-Midnight compliance all in one view.
- Health Information Management (HIM) and Revenue Integrity Teams: Reduce denials and accelerate defensible determinations using structured criteria capture, timing controls, and appeal-ready exports.
- Clinical Informatics and EMR Analysts: Govern status logic, monitor concurrent review fidelity, and surface timing anomalies using dashboard overlays and criteria audit metrics.
- Compliance and Leadership Teams: Leverage summary dashboards to track utilization trends, appeal outcomes, and financial exposure due to delayed or inconsistent reviews.