Full Service Utilization Review
Full Service Utilization Review, Run End to End
You set the program approach. Enlyte runs daily operations across jurisdictions and automatically adjust program due to your changing business needs.
MORE UTILIZATION REVIEW SOLUTIONS
Who It’s For
- Claims leaders who want consistent outcomes and strong operational coverage
- Managed care teams that need scalable daily review operations
- Compliance teams that need audit-ready process discipline
- Operations leaders that need stable throughput across volume swings
Benefits
- Consistent operations that automictically shifts as your business needs change
- Decisions that hold up in appeals and audits
- Configurable rules and workflows by jurisdiction and line of business
Features
Peer Escalation When Needed
Clinical Review with Documentation Standards Embedded Quality Controls
Reporting and Continuous Optimization Support
Genex Services Grievance Process
The Genex grievance process addresses formal complaints about non-clinical, non-determination related Genex processes or services. The grievance process does not address the clinical decision itself. It focuses on concerns with the process or people involved in developing the determination. Examples of grievances could include complaints that the utilization review decision was not completed within timeframes established by the Labor Code, or that the physician who rendered the determination was not licensed.
Resources
Utilization Review Decision Manager (URDM)
Learn how URDM bridges the gap between utilization review and bill processing for better results.
Inside the Digital Shift of New York Workers’ Compensation
Explore the innovative digital transformation of New York's workers' compensation system with the NY Workers' Compensation Board's 2024 conference highlights.
Combatting New Jersey Auto Casualty Challenges
When an auto injury occurs, insurers—especially in New Jersey, where strict requirements apply—often struggle to coordinate with multiple vendors, a challenge addressed along with potential solutions by Ben Roberts, vice president of utilization review at Genex.
URAC Certification
Learn about our URAC accreditation.
Frequently Asked Questions
Can we vary our utilization review program to be configured differently by state?
Yes. Programs can vary by jurisdiction and line of business, based on your goals and requirements.
Why do utilization review results look different from one program to the next, even when both programs are working well?
Results are shaped by what you choose to send into review. Some programs review a wide range of requests, including routine care, while others filter out the straightforward approvals and focus review time on higher-risk, higher-cost, or more complex services. That difference changes your outcome mix and metrics, so the right question is not “Which program denies more?” It is “Is our program built to protect spend, support access to appropriate care, and create defensible decisions based on our goals?”
Can we expand utilization review beyond state-mandated jurisdictions?
Yes. You can expand UR beyond mandated states by using it as a targeted cost-control strategy, not a blanket process. UR is built to prevent medically unnecessary or unreasonable treatment and surgery is one of the highest-impact places to apply that discipline. For example, a large self-insured employer successfully reduced escalating surgical costs by expanding utilization review (UR) beyond states where it was legally mandated to all jurisdictions where regulations permitted it. Enlyte recommended broadening surgical review coverage, applying evidence-based clinical guidelines, and maintaining operational efficiency with a 2-day average turnaround time. The results were impressive: an 80% increase in surgery review volume, 163% increase in total surgical savings to over $1M, and a 34% improvement in gross ROI from 3.73 to 4.98.
Why is clinical rigor so important in utilization review?
Clinical rigor matters in utilization review because it anchors determinations in evidence-based medicine, preventing approvals of unnecessary care that can lead to poor outcomes like avoidable surgeries or inappropriate opioid use. It also produces consistent, defensible determinations with documented rationale and criteria, which strengthens your position in disputes and litigation. Finally, strong controls and clinical oversight keep automation from becoming rubber-stamping so complex, high-risk requests get the right level of human review.
Is your program URAC accredited?
Yes, we have been URAC accredited for utilization review since 1996.
What is the importance of URAC accreditation?
URAC accreditation matters because it adds independent, third-party validation to your UR program, so you can operate with more confidence and credibility.
- Proves disciplined operations: URAC standards emphasize strong foundations like risk management, performance monitoring and consumer protections, which reinforces consistency and quality
- Strengthens trust with payers and regulators: URAC notes its utilization management accreditation is widely recognized across states and at the federal level, which supports acceptance in demanding environments
- Signals ongoing improvement: URAC positions accreditation as independent validation of high-quality health care and a framework that drives continuous improvement, not a one-time checkbox
Let’s Connect
Let’s collaborate to see how we can provide your organization with an effective, efficient and compliant utilization review solution.