Utilization management (UM) was the first role applied in acute care case management models. It was initially 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. This webinar will review the role of utilization management as it applies to today’s contemporary case management models. Each step in the process of utilization management, including the role of the physician advisor and compliance regulations will be discussed. Determining where UM should reside is a common concern for case management leaders—in the RN case manager role or separated. Strategies for making that determination for your department will be discussed. Also 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.
After attending this session, participants will be able to :
- Understand the best-practice process for utilization management for the hospital patient
- Identify the role of the RN case manager in utilization management
- Describe the difference between utilization management and utilization review
- Implement an effective relationship with the physician advisor
- Define the proposed rules for changes to the Conditions of Participation(CoPs) : Utilization Management
- Understand the compliance requirements for hospital utilization management.
- Develop an outcomes dashboard for hospital utilization management.
- Understand the concept of artificial intelligence and the utilization management process
Areas Covered In The Session:
- Utilization management definition
- Medical necessity defined
- UM processes for, and components of, medical necessity
- Compliance components of medical necessity
- CMS Conditions of Participation and UM
- Essential utilization management activities
- Utilization management: Billing and reimbursement
- Best practice in clinical reviews
- Managing utilization from the bedside
- Appropriate UM documentation
- Physician advisor collaboration
- Incorporating UM into your daily routine
- Proactive denial management
- Navigating utilization management with various payers and payment models
- Utilization management separated from the case management function
- UM dashboard for your hospital
- Directors of Case Management
- Director of Finance
- RN Case Managers
- Directors of Social Work
- Directors of Compliance
- Discharge Planners
- Chief Medical Officers
- Physician Advisor
- Case Managers
- Directors of Quality and Outcomes
- Social Workers
- Any Executive Responsible for Case Management
About The Presenter:
Bev Cunningham, MS, RN, ACM is a founding partner of Case Management Concepts, LLC. She has a 25-year deep working knowledge of case management with specific expertise in denials management, the utilization management process, 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 is a well-known speaker and expert in the case management process.
She also co-authored the book Core Skills for Hospital Case Managers and wrote a chapter in most recent two editions of CMSA’s Core Curriculum for Case Management. Bev is also the former Vice President of Resource Management at Medical City Dallas Hospital, where she had responsibility for Case Management, Social Work, Health Information Management, Patient Access and Sold Organ Transplant services.
You will receive an email with login information and handouts (presentation slides) that you can print and share to all participants at your location.
Operating System: Windows any version preferably above Windows Vista & Mac any version above OS X 10.6
Internet Speed: Preferably above 1 MBPS
Headset: Any decent headset and microphone which can be used to talk and hear clearly
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