Analytical and Data-Based Decision Making in Case Management
Hours: 1.75
Millions of people use health insurance in the U.S. The data that healthcare providers (HCPs) provide to insurance companies, or payers, is used to help make decisions based on the medical necessity of the treatment and cost. Data is being applied in ways never before seen by payers and providers to drive healthcare improvement through an analytic approach. Data can be applied to improve healthcare costs, quality, and outcomes. To understand how data is being utilized, you must first understand the broad perspective of what experts are calling the “data revolution” in healthcare, or the “age of big data.” It is also important to know what this means from a technology perspective.
There is also a micro-level of healthcare data application within the payer setting that has different ways in which data is helping payers to improve overall population health, manage healthcare costs, and inform the creation of innovative pilot programs. For those working in a healthcare setting, it is important to know how healthcare data is applied from a payer’s perspective. This includes member case management selection, the intersection of healthcare data and member preference, and how data is being used to inform best practices through medical necessity criteria (MNC) and clinical guidelines.
Millions of people use health insurance in the U.S. The data that healthcare providers (HCPs) provide to insurance companies, or payers, is used to help make decisions based on the medical necessity of the treatment and cost. Data is being applied in ways never before seen by payers and providers to drive healthcare improvement through an analytic approach. Data can be applied to improve healthcare costs, quality, and outcomes. To understand how data is being utilized, you must first understand the broad perspective of what experts are calling the “data revolution” in healthcare, or the “age of big data.” It is also important to know what this means from a technology perspective. There is also a micro-level of healthcare data application within the payer setting that has different ways in which data is helping payers to improve overall population health, manage healthcare costs, and inform the creation of innovative pilot programs. For those working in a healthcare setting, it is important to know how healthcare data is applied from a payer’s perspective. This includes member case management selection, the intersection of healthcare data and member preference, and how data is being used to inform best practices through medical necessity criteria (MNC) and clinical guidelines.
California Board of Registered Nursing
Provider approved by the California Board of Registered Nursing, CEP# 13791
Nurses will receive 1.75 contact hours for participating in this course.
District of Columbia Board of Nursing
District of Columbia Board of Nursing Approved Continuing Education program (CEBroker Provider #50-290).
Nurses will receive 1.7000 contact hours for participating in this course.
Florida Board of Nursing
Florida Board of Nursing (CEBroker Provider #50-290)
Nurses will receive 1.5000 contact hours for participating in this course.
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 1.75 Nursing Contact Hours after successfully completing this course.
Georgia Board of Nursing
Georgia Board of Nursing (CEBroker Provider #50-290)
Nurses will receive 1.75 contact hours for participating in this course.
South Carolina Board of Nursing
South Carolina Board of Nursing (CEBroker Provider #50-290)
Nurses will receive 1.75 contact hours for participating in this course.
West Virginia Board of Registered Nursing
West Virginia Board of Registered Nursing (CEBroker Provider #50-290)
Nurses will receive 1.75 contact hours for participating in this course.
New Mexico Board of Nursing
New Mexico Board of Nursing (CEBroker Provider #50-290)
Nurses will receive 1.75 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 1.75 contact hours for participating in this course.
Kentucky Board of Nursing
Kentucky Board of Nursing (CEBroker Provider #50-290)
Nurses will receive 1.75 contact hours for participating in this course.
Mississippi Board of Nursing
Mississippi Board of Nursing (CEBroker Provider #50-290)
Nurses will receive 1.75 contact hours for participating in this course.
North Dakota Board of Nursing
North Dakota Board of Nursing (CEBroker Provider #50-290)
Nurses will receive 1.75 contact hours for participating in this course.
Association of Social Work Boards
As a Jointly Accredited Organization, Relias LLC is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. State and provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing education credit. Relias LLC maintains responsibility for this course. Social workers completing this course receive 1.75 General continuing education credits.
Course Delivery Format: Asynchronous Distance Learning-interaction includes quizzes with questions and answers, post-tests. This module is Reading-Based Online.
New York State Education Department, Office of the Professions, Division of Professional Licensing Services, Social Work Unit
Relias, LLC is recognized by the New York State Education Department's State Board for Social Work as an approved provider of continuing education for licensed social workers #SW-0009.
Materials that are included in this course may include interventions and modalities that are beyond the authorized practice of licensed master social work and licensed clinical social work in New York. As a licensed professional, you are responsible for reviewing the scope of practice, including activities that are defined in law as beyond the boundaries of practice for an LMSW and LCSW. A licensee who practices beyond the authorized scope of practice could be charged with unprofessional conduct under the Education Law and Regents Rules.
As a provider of online, asynchronous education, some courses offered by Relias Learning are considered “self-study” under section 74.10(c)(2)(ii)(b)(4) of the Commissioner’s Regulations. The regulations limit self-study activities taken from a provider approved by the Education Department to no more than 12 hours in the 36-month registration period or one-third of the hours in a registration period other than 36 months.
Social workers will receive 1.75 continuing education hours for participating in this course. This activity is approved for 1.75 contact hours.
Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling
Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling (CEBroker Provider #50-290)
This activity is approved for 1.75 contact hours.
Ohio Social Worker Board
Ohio Counselor, Social Worker and Marriage and Family Therapist Board (CEBroker Provider # 50-290)
This activity is approved for 1.75 contact hours.
South Carolina Board of Social Work Examiners
South Carolina Board of Social Work Examiners (CEBroker Provider 50-290)
West Virginia Board of Social Work
West Virginia Board of Social Work (CEBroker Provider #50-290)
Commission for Case Manager Certification
This program has been pre-approved by The Commission for Case Manager Certification to provide 1.5000 hours of continuing education credit to CCM® board certified case managers.
Discuss the background and implications of big data in healthcare.
Describe how data is utilized by case managers within different areas of the payer setting to improve care outcomes, measure case management performance, and identify fraud, waste, and abuse.
Explain how data drives better healthcare through evidence-based decision-making, application of medical necessity criteria, and utilization management.
Outline:
Section 1: Introduction
About This Course
Learning Objectives
Section 2: An Introduction to Healthcare Data
Testing Your Existing Knowledge
Overview of Healthcare Data
What is Big Data in Healthcare?
Review
Summary
Section 3: Data Sources
General Data Realms
Specific Data Sources
How Data is Used
Data Challenges
Needed Infrastructure
Potential Future Benefits
Review
Summary
Section 4: Data-Based Decision Making in the Payer Setting
Applying and Utilizing Data in the Payer Setting
Achieving Case Management Goals
Identification for Case Management Services
Critical Measurements During the Case Management Process
Case Management Performance Measures
Utilization Benchmarks and Best Practice Identification
Identifying Fraud, Waste, and Abuse
Data Measurements for Medical Necessity Adherence
Meet Jamal
Review
Summary
Section 5: Detailed Application of Data in Decision Making
Common Areas of Data Within Case Management
Outcome and Utilization Measures for Case Management
Medical Necessity Criteria
Clinical Pathways to Guide Decisions with Data
The Benefits of Data-Based Decision-Making
Review
Summary
Section 6: Conclusion
Course Summary
Course Contributors
Resources
References
Writer: Alia Lutz, BA, BSN, RNWendy Waltrip MSN, RN, CCM has a 23-year nursing career with experience in oncology, medical-surgical, acute rehabilitation, hospice, and nursing leadership. She has 10 years of deep working knowledge of case management with specific expertise in field and telephonic complex chronic condition case management and case management process optimization in managed care, acute, and community settings.
Disclosure: Wendy Waltrip, MSN, RN, CCM has no Relevant Financial or Non-Financial Relationship with ineligible companies to disclose.
Alia Lutz, BA, BSN, RN, has over 10 years of experience as a Registered Nurse with a focus on cardiothoracic, respiratory, and coronary care. She has also had experience in Med-Surg, step-down and ICU. Prior to joining Relias as a SME and Content Writer for acute care, she provided virtual education and injection training on injectable biologics to patients, reported adverse events, and was a patient advocate. She has collaborated with peers on creating job aids, writing policies, and improving quality of care and documentation. Alia received her Bachelors in Nursing from Otago Polytechnic in New Zealand in 2011. Disclosure: Alia Lutz, BA, BSN, RN has no Relevant Financial or Non-Financial Relationship with ineligible companies to disclose.
The target audience for this course is: Case Managers; Intermediate level Social Workers; Nurses; in the following settings: Acute Care Facility.
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.
