Utilization Management: What Does it Really Mean? And Where Should it Reside?

Live Webinar | Catherine M. Mullahy | From: Feb 14, 2019 - To: Mar 29, 2019

Speaker: Catherine M. Mullahy (RN, BS, CRRN, CCM) and Jeanne Boling (MSN, CRRN CDMS, CCM)

Utilization management was the first role applied in acute care case management models. It was first known of as utilization review but has evolved into something much more comprehensive than that. Today it encompasses elements of resource management and denials management as well. Physicians, both the practicing physician and the physician advisor are often left out of this important process and must be included in any contemporary case management utilization management model. This program will review the role of utilization management as it applies to today’s contemporary case management models. Included will be best-practice suggestions for your practice with tips and strategies for stream-lining the process and making it as efficient as it can be.

The challenge of managing the UM process with various payers and varied payment models will also be addressed. Additionally, discussed with be the importance of utilization management collaboration in the case management role, whether it is housed with the RN case manager role or outside of it.

Agenda topics:

- Utilization management definition - Medical necessity defined - Compliance components of medical necessity
- Billing and reimbursement - Best practice in clinical reviews - Managing utilization from the bedside
- Appropriate UM documentation - Proactive denial management And more!


After this webinar participants will be able to:

  1. Describe the differences between utilization review and utilization management.
  2. Discuss the best strategies for managing utilization reviews and other issues relate to utilization management.
  3. Identify ways in which a strong utilization management process can reduce payment denials.

Target Audience:

Anyone involved with or interested in case management, including but not limited to: CEOs, CFOs, COOs, CMOs, CNOs, CE Directors, Department Directors, Quality Improvement Staff, Physicians, Nurses (all levels), Compliance Officers, CMS Liaisons, TJC Liaisons, Registration Staff, Safety Officers and Staff, Pharmacy Staff, Ethics Committee Members, Consumer Advocates, Risk Managers, Legal Counsel, Behavioral Health Staff, Psychiatry Staff, Social Workers, Discharge Planners, Case Managers, Hospice Staff and Regulatory Affairs Staff.

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