Our Managed Care Claims Examiners consist of dedicated teams of experienced Claim Examiners. Deep experience in all lines of business producing exceptionally high quality adjudication.
Our Benefits team provides clients with a standard benefit plan setup & interpretation, with standard event classes & benefit rules. We handle benefit calculations, calculating OOP from plan cost & tracking benefit costs.
Our Eligibility Specialists support a stringent process of verification of member eligibility records and update of member records by verifying Eligibility details online from Health Plans and State enrollment records.
We offer support to New MSO buildouts across three key areas including System Evaluation & Selection, Process & Org Design, Delegation contracting with P&P design, and Pre-delegation readiness support.
Our Review team performs an increased level of research, investigation and independent evaluation of Appeal data in compliance with standard protocols and overall clinical objectives.
The HCC team comprises of expert, clinically-trained coders (CPC, CPC-H) and physicians who engage in highly efficient chart reviews to recover valuable ICD-10 codes for accurate coding of the member population risk level.
Population Health Management
Calibrated strives to support clients in developing a comprehensive population assessment that aims to provide an understanding of the targeted population, population needs, and trends
The Calibrated complex case management interventions are designed to support the high needs, high cost population. This is a smaller, more complex sub-population identified through client defined characteristics. The targeted interventions are tailored to the multiple needs of the population and require a high intense approach
The transition case management interventions are designed to support the safe transfer of a patient from one care setting to another. The CHN transitional case management services reduces the risk of adverse events, miscommunication, readmission, and provides a safe transfer of care during vulnerable patient encounters.
The Calibrated wellness and prevention interventions are designed to allow members to make active, informed decisions that promote positive health outcomes and may include health education, disease-specific education for self-management, outreach for care gap closure for HEDIS/ P4P measures
The nurse advice line and contact center can be an extension of provider offices or medical management operations either during office hours and/ or after hours and weekends based on clients needs to direct members to the appropriate level of care, provide authorization support or perform targeted outreach campaigns
The Calibrated care gap outreach program assist clients in closing care gaps to improve quality performance and value based reimbursement opportunities
The Calibrated contact center services include the collection of information for annual health risk assessments and reassessment within required timelines to support population health strategies
The Calibrated UM Program offers clinical and non-clinical levels of prospective, concurrent, and retrospective reviews to ensure quality-based, cost-effective management of healthcare resources.
Calibrated employs trained clinicians to partner with hospitalists or attending physicians to facilitate a safe and effective discharge plan from an inpatient or skilled nursing level of care. Clinicians perform concurrent review to determine medical necessity of admission, continued stay, and appropriateness of level of care.
Calibrated aims to support hospital revenue cycle recovery programs through aggressive appeal management for medical and behavioral acute care denials.
Calibrated clinical documentation improvement team reviews retrospective ED claims to ensure the appropriate level of care for cost effective use of healthcare resources.
Calibrated can provide clients with specialty referral tracking services that include assisting dependent members with specialist appointment scheduling, confirming appointment adherence, and assistance with provider exchange of information through the contact center
Calibrated aims to support clients in the accurate processing of denial, modification, or pend notifications to ensure communications meet regulatory guidelines in terms of content, form, and timeliness