Hospital Case Management 101: Utilization Management


Event Date: TBD
Time: 1 pm ET | 12 pm CT | 11 am MT | 10 am PT
Duration of the training: 60 Minutes
Location: Online Webinar
By: Beverly Cunningham, MS, RN, ACM

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:

Beverly Cunningham, MS, RN, ACM was most recently Vice President, Resource Management at a large acute care hospital. Her areas of responsibility included Case Management, Health Information Management, Patient Access, Solid Organ Transplant and Transplant Financial Services.

She has also been a Clinical Assistant Professor for the Master of Nursing Program at the University of Oklahoma, where she coached students in their clinical practicums. Bev is a well known speaker in the Case Management field. Involved in the development of case management for over twenty-five years, her areas of expertise include denials management, patient flow and the role of the Case Manager and Social Worker in the Case Management process. She has served as a Commissioner on the Commission for Case Management Certification and is a fellow with the Advisory Board. She has achieved ACM certification by the American Case Management Association. Bev’s publications include a chapter in CMSA’s third edition of Core Curriculum for Case Management Certification and most recently, co-author of the book, Core Skills for Hospital Case Management.

Bev has a BSN from Pittsburg State University, Pittsburg, Kansas and a Master of Science, Nursing Major, from the University of Oklahoma.