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This is the first webinar in a series of four webinars. It will focus on the earliest role of the RN case manager: utilization management (UM). Subsequent webinars will include the foundations of care coordination, discharge planning and collaboration with other case manager roles.

UM was first known as utilization review but has evolved as a process much more comprehensive than review. Today it encompasses elements of resource management and denials management as well. This webinar is designed to provide a fundamental understanding for RNs, new to the RN case manager role as well as RNs who have been in the role but missed previous orientation. It can also be a refresher for RNs who may be struggling with implementing each of the steps in the utilization management process.

Whether the RN case manager on a hospital unit has total responsibility for utilization management or not, it is imperative that there is understanding of the UM process. The basics of the role of utilization management as it applies to today’s contemporary case management models will be explained. Included will be best-practice suggestions for your practice with tips and strategies for streamlining the process and making it as efficient as it can be. Additionally, government, state and payer rules and regulations impacting the UM process will be discussed.

Collaboration in the RN case manager role is critical. Strategies are necessary as the case manager collaborates with physicians, advance practice practitioners, nursing, and ancillary services will be provided. Physicians are often not intuitive in their understanding of utilization management. The RN case manager has responsibilities for not only understanding the UM process, but sharing that process with care providers, be it attending or consulting physicians, ED physicians or the physician advisor. Steps for effective collaboration with a physician advisor will be introduced.

Learning Objectives:

• Describe the differences between utilization review and utilization management
• Understand the role of utilization management for the RN case manager
• Discuss the best practices for managing utilization reviews and other issues related to utilization management
• Identify ways in which your strong utilization management process can reduce payment denials
• Review collaboration efforts with key stakeholders, including case management, colleagues, physicians, physician advisors and those services patient care
• Discuss compliance requirements for utilization management
• Develop outcomes for utilization management

Areas Covered in the Session:

• Utilization management definition
• Difference between utilization review and utilization management
• Medical necessity defined
• UM processes for and components of medical necessity
  • When patient meets medical necessity
  • When patient does not meet medical necessity
• Compliance components of medical necessity
• Conditions of Participation by CMS and utilization management
• Essential case management department activities
• Utilization management and billing
• Utilization management and reimbursement
• Best practice in clinical reviews
• Managing utilization from the bedside
• Appropriate UM documentation
• Collaboration in utilization management
  • Practicing physicians
  • Physician advisor
  • Utilization Management Committee physicians
• Incorporating UM into your daily routine
• Managing denials before they happen
• Payer communication and collaboration
• Tracking outcomes of utilization management functions
• Live Q&A session

Suggested Attendees:

• Acute care RN case managers new to the role of ready for a refresher
• Acute care utilization managers
• Hospital case management leaders
• Physician Advisors (especially those new in the role)
• Acute care and long-term care RN case managers, critical access hospitals
• CFOs or executives responsible for case management
• Directors of Case Management
• Director of Finance
• RN Case Managers
• Directors of Social Work
• Directors of Compliance
• Discharge Planners
• Chief Medical Officers
• Case Managers
• Directors of Quality and Outcomes
• Social Workers
• Any Executive Responsible for Case Management

Presenter Biography:

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This is a Live Virtual session.

A new way of immersive learning that allows you to engage live with our instructor and peers providing you with the flexibility to juggle the new work-life balance.

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Snippet From Our Previous Session