URAC Health Care Management Certification Consulting

Last updated: April 2026

URAC Health Care Management (HCM) Certification is the credential for healthcare organizations that operate in the healthcare industry but fall outside the eligibility requirements for URAC's program-specific accreditations. IHS guides organizations through every phase — gap analysis through certification — led by Thomas G. Goddard, JD, PhD, former Chief Operating Officer and General Counsel of URAC.

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What Is URAC Health Care Management Certification?

URAC Health Care Management (HCM) Certification: a three-year quality credential awarded by the Utilization Review Accreditation Commission (URAC) to healthcare organizations that demonstrate compliance with URAC's Foundational Focus Area standards — and that do not qualify for a program-specific URAC accreditation such as Case Management, Health Utilization Management, Patient Care Management, or Pharmacy Benefit Management.

HCM Certification is one of only two URAC certification programs (as distinct from accreditation programs). It is purpose-built for the segment of the healthcare ecosystem that performs critical functions — care coordination support, subcontracted clinical operations, health technology services, specialty administrative functions — but does not operate a discrete clinical program that maps to an existing URAC program standard set.

The certification is grounded in four Foundational Focus Areas:

• Risk Management — organizational governance of operational and clinical risk; security, privacy, and business continuity
• Operations and Infrastructure — policies, procedures, staffing qualifications, oversight, and delegation management
• Performance Monitoring and Improvement — quality management program structure, performance measurement, and ongoing improvement processes
• Consumer Protection and Empowerment — consumer safety, complaint and grievance processes, and communication standards

These four areas are the structural backbone underlying most URAC accreditation programs. HCM Certification applies them to organizations whose operational scope does not fit neatly within a single URAC program category.

Who Needs URAC Health Care Management Certification?

Any healthcare organization that (1) operates in the healthcare industry, (2) seeks external validation of operational quality, and (3) does not qualify for another URAC accreditation or certification program is a candidate for HCM Certification. URAC does not certify or accredit individuals.

Organizations that frequently pursue HCM Certification include:

• Healthcare technology and analytics vendors — organizations providing decision support tools, clinical data platforms, or population health analytics to health plans, employers, or providers
• Subcontracted health operations companies — entities performing delegated functions (e.g., member outreach, prior authorization support, care transitions coordination) on behalf of URAC-accredited health plans or managed care organizations
• Specialty administrative service organizations — organizations managing disease management program logistics, wellness program administration, or complex care navigation for employer groups or health systems
• Care coordination platforms — technology-enabled organizations that facilitate care coordination across providers and settings without directly owning a clinical program
• Health plan support organizations — entities providing quality improvement, credentialing support, compliance monitoring, or regulatory reporting services to health plans and managed care organizations
• Emerging healthcare service organizations — organizations building new lines of healthcare service where a URAC program-specific standard does not yet exist or where the organization's scope spans multiple program categories

The common thread: these organizations touch patient care, work alongside or within URAC-accredited systems, and need a recognized external validation credential — but their operational scope does not map to a single existing URAC program.

Why HCM Certification Matters

B2B Credentialing and Contracting

Health plans, managed care organizations, and self-funded employers increasingly require their vendors and subcontractors to hold recognized quality credentials as a condition of contracting. HCM Certification provides a URAC-recognized seal that communicates operational quality and regulatory alignment to partners, procurement teams, and compliance officers — without requiring the organization to pursue a full program-specific accreditation that exceeds its operational scope.

Regulatory and Payer Alignment

As CMS, state regulators, and accrediting bodies extend quality expectations further into the healthcare supply chain, vendors and subcontractors that operate without external validation face growing scrutiny. HCM Certification positions organizations ahead of this trend by establishing a documented, externally-verified quality baseline.

Operational Improvement Through the Certification Process

The certification process itself drives operational value. The gap analysis and policy development phases systematically surface operational risks — documentation gaps, undefined workflows, delegation oversight failures, consumer communication deficiencies — that organizations may not identify through internal review. Organizations routinely exit the certification process with materially stronger operational infrastructure than they entered with.

Competitive Differentiation

In competitive bid processes and RFP responses, holding URAC HCM Certification is a differentiator. It signals that an external reviewer has verified the organization's policies, procedures, staffing oversight, consumer safety practices, and quality management systems — not just that the organization claims to have them.

What the HCM Certification Standards Cover

URAC's HCM Certification standards are derived from the Foundational Focus Areas that anchor most URAC accreditation programs. The standards evaluate operational soundness across four domains:

Risk Management

Organizational governance structures, security and privacy programs, business continuity and disaster recovery planning, and incident management. Surveyors evaluate whether the organization has documented risk identification and mitigation processes, maintains appropriate security protocols for protected health information, and has tested continuity plans that are more than paper exercises.

Operations and Infrastructure

Policies and procedures governing the organization's core operations, staffing qualifications and oversight, delegation management for subcontracted functions, and ongoing training programs. This is typically the heaviest documentation area — URAC expects policies that reflect actual operations (not aspirational ones), with evidence that staff are trained and operating accordingly.

Performance Monitoring and Improvement

Quality management program structure, selection and tracking of performance measures, analysis of performance data, and documented improvement actions. Organizations must demonstrate a functioning quality management system — not just a Quality Improvement plan on paper, but an operational process that produces measurable results and responds to performance data with corrective action.

Consumer Protection and Empowerment

Consumer safety protocols, complaint and grievance handling processes, communication standards (including health literacy requirements for consumer-facing materials), and escalation pathways. Even organizations without direct consumer interaction have responsibilities under this focus area — typically through policies governing how consumer-affecting decisions are documented, communicated, and appealable.

Unlike program-specific URAC accreditations, URAC does not prescribe how organizations meet the HCM Certification standards — the standards define what must be demonstrated, and organizations have flexibility in how they build their compliance framework. This flexibility is an asset for organizations with innovative operating models that do not fit prescriptive program templates.

The HCM Certification Process

URAC markets HCM Certification as completing in less than six months. The process follows a structured sequence:

1. Standards Acquisition — The organization purchases the HCM Certification standards from the URAC store. IHS advises on the specific standards package and any supplemental standards that apply to the organization's operational context.
2. Gap Analysis (Standard-by-Standard Review) — The organization's current policies, procedures, and operations are evaluated against each HCM Certification standard. IHS produces a prioritized gap report identifying deficiencies, documentation gaps, and operational areas requiring remediation before submission.
3. Policy Development and Process Engineering — IHS drafts or revises compliance documentation to address identified gaps: policies, procedures, job descriptions, delegation agreements, quality management program documentation, consumer communication templates, and operational workflow documentation. The organization begins operating under new procedures immediately to begin building operational evidence.
4. Mock Survey — IHS conducts an internal review simulating the URAC survey process. Staff are interviewed on key operational areas. Documentation is evaluated for completeness and alignment with standards. Remaining gaps are identified and remediated before AccreditNet submission.
5. AccreditNet Submission — Required documentation is assembled and uploaded to URAC's AccreditNet platform. IHS organizes the submission to be reviewer-friendly — each document mapped to its applicable standard with cross-references for documentation satisfying multiple standards.
6. URAC Review and RFI Response — URAC's review team evaluates the submission and may issue Requests for Information (RFIs) seeking additional documentation or clarification. IHS drafts all RFI responses, providing evidence-backed documentation that directly addresses each reviewer concern.
7. Certification Award — Upon successful review, URAC awards HCM Certification for three years. IHS provides guidance on annual maintenance requirements and the renewal cycle.

The IHS Approach to HCM Certification

IHS brings a specific advantage to HCM Certification engagements: Thomas G. Goddard, JD, PhD served as the former Chief Operating Officer and General Counsel of URAC. He helped develop the standards framework that HCM Certification draws from. He knows how URAC surveyors read documentation, what they are looking for when they evaluate policies, and where organizations predictably fall short.

Standard-by-Standard Review

Every HCM Certification engagement begins with a systematic review of the organization's operations against each standard. This is not a high-level assessment — it is a line-by-line evaluation of policies, procedures, contracts, job descriptions, and operational evidence against the specific language of each standard. The output is a prioritized remediation roadmap, not a generic "areas for improvement" summary.

Policy Development That Reflects Actual Operations

URAC surveyors distinguish immediately between policies written to satisfy a checklist and policies that reflect how an organization actually operates. IHS writes compliance documentation by first understanding the organization's real operational workflows, then building policies and procedures that are both standards-compliant and operationally accurate. This approach eliminates the surveyable gap between written policy and observed practice.

Mock Survey with Operational Staff

IHS conducts mock surveys that mirror the URAC review process — including staff interviews on core operational areas, documentation review, and process walkthroughs. The mock survey identifies issues that documentation review alone misses: staff who cannot articulate the procedure they are supposed to follow, workflows that work differently in practice than on paper, and documentation gaps that only surface when a real question is asked.

AccreditNet Submission Architecture

How a submission is organized affects how a reviewer reads it. IHS structures AccreditNet submissions to make the reviewer's job easier — clear standard-by-standard mapping, consolidated documentation where multiple standards share evidence, and explanatory context that guides reviewers to the right evidence without requiring them to hunt for it. This approach consistently reduces RFI volume and accelerates review timelines.

RFI Response

If URAC issues RFIs, IHS drafts the responses. RFI responses require precision: the reviewer has identified a specific gap, and the response must directly address that gap with evidence — not restate the policy that was already submitted. IHS's familiarity with URAC reviewer expectations produces responses that resolve RFIs efficiently rather than generating secondary rounds of follow-up.

Common HCM Certification Challenges

Policies That Do Not Reflect Operations

The most common failure mode in URAC reviews — across all programs, including HCM Certification — is the gap between written policy and operational practice. Organizations draft policies to satisfy a standard, then operate differently. URAC surveyors interview staff, review operational records, and look for evidence that the organization is actually doing what its policies say it does. Policies written without operational grounding are a direct path to RFIs and adverse survey findings.

Quality Management Systems That Exist Only on Paper

Performance Monitoring and Improvement standards require functioning quality management systems — committees that meet regularly, documented performance data, evidence of corrective actions taken in response to identified deficiencies. Organizations that have a Quality Improvement Plan but no operational QM infrastructure fail this domain consistently. Building a functioning QM system requires time — it cannot be constructed in the weeks before survey submission.

Delegation Oversight Gaps

Organizations that subcontract functions often underestimate the documentation requirements for delegation oversight. URAC's Operations and Infrastructure standards require evidence of ongoing oversight of delegated activities — not just executed delegation agreements. Periodic audits, documented issue identification, and corrective action tracking are all required. Organizations discover these gaps during mock surveys when they cannot produce delegation audit records.

Consumer Communication Deficiencies

Consumer Protection and Empowerment standards govern how organizations communicate with consumers — including health literacy requirements for consumer-facing materials, complaint process documentation, and escalation pathways. Organizations that touch consumer-affecting processes indirectly (e.g., through subcontracted health plan operations) often overlook these requirements, assuming they apply only to direct consumer interactions.

Security Documentation Gaps

Risk Management standards require documented security and privacy programs, business continuity plans, and evidence of testing. Organizations with robust security practices but minimal documentation consistently face RFIs in this domain. The issue is not the security posture — it is the absence of documented evidence that surveyors can review.

Related URAC Programs

HCM Certification is designed for organizations that do not qualify for program-specific URAC accreditations. As an organization grows or its operational scope expands, it may become eligible for — or required to pursue — a program-specific credential. IHS helps organizations assess which credential is appropriate for their current operational scope and plan for transitions as scope evolves.

• URAC Case Management Accreditation (CM v7.0) — for organizations managing complex or chronic patient cases across care settings
• URAC Health Utilization Management Accreditation (HUM v8.2) — for organizations performing prior authorization and clinical review functions
• URAC Patient Care Management Accreditation — for organizations delivering comprehensive disease management and patient care support
• URAC Pharmacy Benefit Management Accreditation — for PBMs and specialty pharmacy benefit managers
• URAC Health Network Accreditation — for preferred provider organizations and health network administrators

IHS advises on the full URAC program portfolio and helps organizations identify the right credential — or credential sequence — for their specific operational model and market position.

Start Your HCM Certification Engagement

IHS works with healthcare organizations at every stage — from organizations pursuing HCM Certification for the first time to organizations transitioning from HCM Certification to a program-specific URAC accreditation as their scope expands. Every engagement begins with a discovery conversation to assess organizational readiness, identify the right credential, and scope the consulting engagement.

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