Striking the Right Balance Between Quality and Cost.
At Elm & Oak, we understand the difficult balancing act of ensuring that every member gets the right care at the right time without overuse, delays, or unnecessary expense. Our Utilization Management program helps payers and providers walk that line with confidence.
Data-Driven Decisions. Human-Focused Care.
Utilization Management (UM) plays a critical role in aligning care delivery with both clinical need and financial responsibility. But it’s not about saying “no.” It’s about ensuring the right resources are deployed efficiently and equitably, particularly in government-sponsored programs like Medicaid, Medicare Advantage, and Special Needs Plans serving complex populations.
Our approach uses nationally recognized, evidence-based criteria to ensure consistent, defensible decision-making. What sets us apart is our ability to apply those standards within programs serving members with significant medical, behavioral, and social needs, and to link clinical protocols with real-time insights and care coordination.
The result is smarter care that supports both individual health and system sustainability.
Built for Public Programs. Designed for Real Life.
Elm & Oak serves government-sponsored programs across the healthcare landscape. Our UM programs are structured to address the unique clinical, regulatory, and cost challenges faced by Medicaid Managed Care Organizations, Medicare Advantage Plans, and plans serving Special Needs populations.
This includes environments where utilization decisions must account for high-acuity conditions, social risk factors, and the realities of delivering care to underserved communities. Our process starts with detailed analytics and proven workflows to ensure compliance, timeliness, and medical appropriateness of care. But we don’t stop at authorization decisions.
Our UM team works closely with care management staff to flag high-risk members, reduce duplication, and close gaps in care, particularly for populations requiring more intensive coordination and oversight.
Expertise, Insight, and Results Working Together
Experienced Clinical Reviewers
An interdisciplinary team of physicians, RNs, and LCSWs with deep experience reviewing care for high-acuity populations, including members with complex medical, behavioral, and social needs.
Evidence-Based Decision Standards
Consistent use of nationally recognized medical necessity criteria to ensure defensible, guideline-aligned determinations across diverse public program environments.
Collaborative, Insight-Driven Support
A partnership-based approach that aligns program goals and uncovers utilization trends to inform broader care and population health strategies.
Integrated Care Management Coordination
Proactive identification of high-risk members and seamless coordination across UM and care teams using real-time analytics, particularly for populations requiring intensive clinical and community-based support.
Certified Utilization Review Agent
Full compliance as a designated Utilization Review Agent, eligible to serve as a UM vendor across diverse state programs.
Our clients have seen meaningful results, including:
Reduced inpatient admissions and ED utilization- Improved adherence to evidence-based care pathways
- Better alignment of service intensity with medical need
- Fewer avoidable delays in care transitions
- Outstanding compliance track record
- Proven ability to support utilization oversight for high-risk, high-complexity member populations
Want to Learn More About Our UM Capabilities?
We tailor every UM engagement to meet the needs of the population, the goals of the organization, and the realities of today’s healthcare system. Let’s talk about how we can partner to drive smarter, more equitable care.
Contact Us to Start the Conversation