Health Cloud · October 10, 2023
Utilization Management with Salesforce Health Cloud
Utilization Management (UM) in healthcare involves assessing the effectiveness, suitability, and medical justification of treatments, services, and procedures. Salesforce Health Cloud provides the infrastructure to do this at scale — centralized data, streamlined workflows, and evidence-based decision support.
The Core Problems UM Solves
Escalating Costs
Healthcare spending continues rising, straining budgets and limiting patient access. UM reduces unnecessary treatments and tests by ensuring care aligns with clinical necessity.
Scattered Patient Data
Patient data fragmented across multiple systems hinders care coordination. Health Cloud centralizes this data, giving UM reviewers a complete picture for better decisions.
Workflow Inefficiencies
Complex administrative procedures delay care delivery. UM within Health Cloud streamlines authorization workflows so treatments are approved and delivered faster.
Medical Errors
Inappropriate or redundant treatments increase error risk. Evidence-based decision support within UM reduces these occurrences by standardizing clinical review.
Patient Engagement
Patients demand transparency and involvement in their care. Patient-focused UM tools enhance satisfaction by making the review process visible and accessible.
Key UM Features in Health Cloud
Medical Necessity Assessment
Evaluate whether treatments align with clinical needs using objective, evidence-based criteria.
Clinical Guidelines
Evidence-based standards ensure care follows established best practices across all reviewers.
Streamlined Authorization
Standardized, efficient review processes reduce administrative burden and speed approvals.
Peer Review
Healthcare experts provide impartial evaluation of treatment necessity when cases are escalated.
Cost Containment
Controls expenses by flagging unnecessary spending that does not benefit patient outcomes.
Appeals Process
Patients and providers can challenge denial decisions through a structured review workflow.
Why the Combination Works
Utilization Management without a proper platform becomes a manual, paper-based bottleneck. Salesforce Health Cloud without UM processes is data without structure. Together, they create a healthcare solution that addresses critical operational challenges, promotes efficient resource distribution, and improves care quality while controlling costs. The result is a UM program that's defensible, auditable, and scalable.
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