Effective Strategies for Achieving Cost


When it comes to achieving success in payer settings, finding the optimal balance between cost of care and quality of outcomes is essential. This course will focus on fundamental knowledge points needed to improve quality and decrease healthcare costs within the payer environment. In this course, you will learn to apply evidence based practices used to improve health outcomes for member populations. Additionally, you will learn the role of medical necessity criteria and application of medical necessity criteria frameworks to create a roadmap for optimal care that is financially responsible. Finally, you will learn about the role of utilization management including common misconceptions about the purpose of utilization management, key metrics every utilization manager needs to be aware of, and the review and appeals process.


Hours: 1.00


Certificates provided by accrediting body (9 Match)

Association of Social Work Boards


Relias, LLC, #1273, is approved as a provider for social work continuing education by the Association of Social Work Boards (ASWB) www.aswb.org, through the Approved Continuing Education (ACE) program. Relias, LLC maintains responsibility for the program. ASWB Approval Period: 2/10/2018-2/10/2021. Social workers should contact their regulatory board to determine course approval for continuing education credits.

Course Delivery Format: Asynchronous Distance Learning-interaction includes quizzes with questions and answers, posttests. This module is Reading-Based.

Social workers participating in this course will receive 1.00 Clinical continuing education clock hours.

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 1.00 continuing education hours for participating in this course. This activity is approved for 1.00 contact hours.

California Board of Registered Nursing


Provider approved by the California Board of Registered Nursing, CEP# 13791

Nurses will receive 1.00 contact hours for participating in this course.

District of Columbia Board of Nursing


DC-RN -- District of Columbia Board of Nursing Approved Continuing Education program (CE Provider #50-290).

Nurses will receive 1.00 contact hours for participating in this course.

Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling


Provider #50-290 This activity is approved for 1.00 contact hours.

Florida Board of Nursing


Florida Board of Nursing CE Provider #: 50-290

Nurses will receive 1.00 contact hours for participating in this course.

American Nurses Credentialing Center


Relias, LLC is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

Nurses will receive 1.00 contact hours for participating in this course.

Georgia Board of Nursing


Georgia Board of Nursing CE Provider #: 50-290

Nurses will receive 1.00 contact hours for participating in this course.

Commission for Case Manager Certification


This activity is approved for 1.00 contact hours.

Course Details

Course Code: REL-PI-0-ESAC
Hours: 1
Type: Online Course
Content Expiration Date: 6/30/2019
Learning Objectives:
Explain the need for balancing cost and quality in the healthcare industry.

Explain the use of evidence based practices and medical necessity criteria within utilization management and utilization review.

Describe the role that utilization management and utilization reviewers play in driving both cost effective and high quality services in the payer setting.

Summarize the appeals and review process.

Section 1: Introduction A. About This Course B. Learning Objectives Section 2: Understanding Cost Quality Balance A. The Need for Balancing Cost and Quality B. Position of Payers C. Defining Efficiency, Quality, and Value D. The Healthcare Triple Aim E. Introduction to Concepts and Relationships F. Review G. Summary Section 3: Evidence Based Practices A. Defining EBP B. Applying EBP C. EBP in the Payer Setting D. Cost Effective Services E. Informed Choice F. The Need for Informed Choice G. Evidence Based Practice Selection H. Common Examples I. Review J. Summary Section 4: Medical Necessity Criteria A. Defining MNC B. The Three Requirements C. Relationship between EBP, Benefits Coverage, and MNC D. Commonly Utilized MNC E. Review F. Summary Section 5: Utilization Management A. An Introduction B. Function of Utilization Management C. Misconceptions D. The Review Process E. Approvals and Denials F. Appeals G. Review H. Summary Section 6: Conclusion A. Summary B. Course Contributor C. Resources D. References E. Congratulations

Instructor: Danyell Jones
Danyell Jones is a recognized leader in the healthcare industry with more than 10 years of diverse experience at the executive level. Ms. Jones has been published in a number of leading healthcare industry magazines and journals, and has been responsible for the development and execution of training programs for some of the nation’s largest Managed Care, Insurer, Provider, and Health System organizations. Disclosure: Danyell Jones has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.
Target Audience:
The target audience for this course is: intermediate and advanced level Case Managers; intermediate and advanced level Nurses; intermediate and advanced level Social Workers; in the following settings: All Healthcare Settings.
Relias will be transparent in disclosing if any commercial support, sponsorship or co-providership is present prior to the learner completing the course.
Course Delivery Method and Format
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.