Quality Series: Utilization Management
Hours: 0.50
Efforts to reduce costs in healthcare encompass a host of strategies, including evidence-based clinical guidelines for high-quality care. Additionally, the use of a lower level of care and outpatient services can result in shorter inpatient acute care stays. Utilization management (UM) personnel conduct reviews to identify the appropriate level of care for patients using evidence-based practices and medical necessity criteria. The reviews also identify avoidable and unavoidable delays that may impact the delivery of care. Clinicians performing utilization reviews collaborate with the multidisciplinary team daily to address patient needs. Nurses working in the acute care setting need to understand the criteria used for utilization reviews and the importance of their role in documenting and communicating patient care.
The goal of this course is to educate nurses about the impact of utilization reviews and how they are connected to quality surveillance.
Efforts to reduce costs in healthcare encompass a host of strategies, including evidence-based clinical guidelines for high-quality care. Additionally, the use of a lower level of care and outpatient services can result in shorter inpatient acute care stays. Utilization management (UM) personnel conduct reviews to identify the appropriate level of care for patients using evidence-based practices and medical necessity criteria. The reviews also identify avoidable and unavoidable delays that may impact the delivery of care. Clinicians performing utilization reviews collaborate with the multidisciplinary team daily to address patient needs. Nurses working in the acute care setting need to understand the criteria used for utilization reviews and the importance of their role in documenting and communicating patient care. The goal of this course is to educate nurses about the impact of utilization reviews and how they are connected to quality surveillance.
District of Columbia Board of Nursing
District of Columbia Board of Nursing Approved Continuing Education program (CEBroker Provider #50-290).
Nurses will receive 0.50 contact hours for participating in this course.
Commission for Case Manager Certification
This program has been pre-approved by The Commission for Case Manager Certification to provide 0.5000 hours of continuing education credit to CCM® board certified case managers.
American Nurses Credentialing Center
In support of improving patient care, Relias LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Nurses will receive 0.50 Nursing Contact Hours after successfully completing this course.
Georgia Board of Nursing
Georgia Board of Nursing (CEBroker Provider #50-290)
Nurses will receive 0.50 contact hours for participating in this course.
South Carolina Board of Nursing
South Carolina Board of Nursing (CEBroker Provider #50-290)
Nurses will receive 0.50 contact hours for participating in this course.
New Mexico Board of Nursing
New Mexico Board of Nursing (CEBroker Provider #50-290)
Nurses will receive 0.50 contact hours for participating in this course.
Arkansas State Board of Nursing
Arkansas State Board Of Nursing Approved Continuing Education program (CEBroker Provider #50-290).
Nurses will receive 0.50 contact hours for participating in this course.
Kentucky Board of Nursing
Kentucky Board of Nursing (CEBroker Provider #50-290)
Nurses will receive 0.50 contact hours for participating in this course.
Mississippi Board of Nursing
Mississippi Board of Nursing (CEBroker Provider #50-290)
Nurses will receive 0.50 contact hours for participating in this course.
North Dakota Board of Nursing
North Dakota Board of Nursing (CEBroker Provider #50-290)
Nurses will receive 0.50 contact hours for participating in this course.
Describe the components of reviews conducted by utilization management personnel and how common criteria, regulations, and clinical practice standards are used during reviews.
Describe how utilization management impacts variances in and quality of healthcare services.
Outline:
Section 1: Introduction
About This Course
Learning Objectives
Section 2: Utilization Management (UM)
History
Current Practice
Utilization Review Team
What Does UM Do?
Utilization Review Tools
Sources for Utilization Review
Review
Summary
Section 3: Utilization Review Process and Assessments
Process
Denials
Appeals
Utilization Review Assessments
Review
Summary
Section 4: Utilization Review and Quality of Care
Variances
Impact of Utilization Review
Role of Bedside Nurses and Providers
Review
Summary
Section 5: Conclusion
Course Summary
Course Contributors
Resources
References
Cathryn Ayers, RN, MSN has nearly 10 years of critical care experience. She was active in multiple committees to improve patient safety, executed staff education activities, and managed the new graduate orientation program for those entering intensive care units. Cathryn obtained a license for massage and bodywork therapy in 2012 and graduated from the University of North Carolina at Greensboro in 2016 with a Master of Science in Nursing Education. She has provided telephonic case management services and developed program materials to facilitate positive outcomes for people with rare conditions across the United States. Cathryn has a passion for teaching and helping others to be their best. Disclosure: Cathryn Ayers, RN has no Relevant Financial or Non-Financial Relationship with ineligible companies to disclose.Expert Reviewer: Barbara A Fuchs, RN, MS, CPHQ, FNAHQ, FACEHP
Barbara A Fuchs, RN, MS, CPHQ, FNAHQ, FACEHP has over 25 years of experience in healthcare. She has had leadership roles in utilization management, case management, and continuing medical education as both a provider and pharma education grant funding. She served as a subject matter expert and contributor for the Commission for Case Manager Certification’s “Case Management Body of Knowledge” website. She is an independent consultant and subject matter expert. Barbara’s mission is to provide strategies and methods to improve patient care and mentor those dedicated to continuing professional development. Disclosure: Barbara A Fuchs, RN, MS, CPHQ, FNAHQ, FACEHP has no Relevant Financial or Non-Financial Relationship with ineligible companies to disclose.
The target audience for this course is: Nurses.
Asynchronous/Online Distance Learning; please see certificate details for specifics on delivery format.
Relias has a grievance policy in place to facilitate reports of dissatisfaction. Relias will make every effort to resolve each grievance in a mutually satisfactory manner. In order to report a complaint or grievance please contact Relias.
If you require special accommodations to complete this module, please contact Relias Support by completing the web form (https://www.relias.com/help) or by using the chat functionality.
All courses offered by Relias, LLC are developed from a foundation of diversity, inclusiveness, and a multicultural perspective. Knowledge, values and awareness related to cultural competency are infused throughout the course content.
Reference herein to any specific commercial product, process, or service by trade name, trademark, service mark, manufacturer or otherwise does not constitute or imply any endorsement, recommendation, or favoring of, or affiliation with, Relias, LLC.
All characteristics and organizations referenced in the following training are fictional. Any resemblance to any actual organizations or persons living or dead, is purely coincidental.
To earn continuing education credit for this course you must achieve a passing score of 80% on the post-test and complete the course evaluation.
If you require special accommodations to complete this module, please contact Relias Customer Support here.
