Course Code: REL-PI-0-ESAC
Type: Online Course
Content Expiration Date: 3/31/2021
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
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.
The target audience for this course is: Advanced, Intermediate level Social Workers; Case Managers; Nurses; 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.
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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.
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