Over recent years, the healthcare management industry has seen dramatic changes. Among them are the function and role of utilization management, which has evolved as a system to evaluate medical necessity and appropriateness of care related to optimal outcomes. The terms utilization review and UM are often used interchangeably. UR is the process of reviewing use, delivery and cost effectiveness of healthcare provided. UM uses the same process, but encompasses additional functions, including processes that improve patient outcomes and resource utilization. UM monitors appropriateness of care, resource allocation and demonstration of medical necessity using specific criteria. This course describes the origins and purpose of UM, including a comparison of concurrent and retrospective review. It also provides an overview of UM roles and responsibilities and defines medical staff‘s responsibility for the process.
This program has been pre-approved by The Commission for Case Manager Certification to provide 4.00 hours of continuing education credit to CCM® board certified case managers.
Teresa Treiger, MA, RNBC, CCM, CHCQM, FABQAURP, is an industry thought leader inspiring Conscious Case Management© practice across the healthcare continuum through public speaking, professional education, peer mentoring, and publication of professional literature. Disclosure: Teresa M. Treiger, MA, RN-BC, CHCQM-CM/TOC, CCM has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.Expert Reviewer: Christina Davis, RN, MS, CMAC
Disclosure: Christina Davis, RN, MS, CMAC has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.
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