This course has been approved for 8 hours by the Commission on Case Manager Certification for 1/15/10 through 12/31/10, 2011, 2012, and 2013.
The purpose of this utilization review continuing education program is to provide nurses with the basic principles of utilization management. After studying the information presented here, you will be able to:
- Define utilization management and explain its origins and purpose
- Describe the role of the utilization review committee
- Identify criteria used in the utilization management process
- Name five types of review and discuss when each is used
- Compare the nursing clinical process to the nursing utilization process
- Explain how patient care pathways are influential in the utilization process
- Differentiate between Medicare and Medicaid
- Describe HMO, PPO and independent practice association models
- Identify two areas within utilization management that are affected by the Health Insurance Portability and Accountability Act
- Explain the managed care concept and describe how it affects utilization management
- Describe three types of data collection that are significant for measuring outcomes in the utilization process
- Identify the principal components of criteria for admission, continued stay and discharge in the mental health and chemical dependency setting
- Discuss the role and responsibilities of the utilization professional in the skilled nursing, home health and external review settings
- Describe the legal responsibilities of the utilization professional
- List five characteristics of a successful reviewer
