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Utilization Management:
The Foundation of Case Management

 

Author/Presenter:

 

 

Length of Program: 120 minutes

 

Course Description:

With the 6th Scope of Work, the Medicare PROs are now mandated to spend one-third of their contract time on inpatient and outpatient utilization management issues. This program is designed to help nursing leaders and case management staff ensure that they are conducting Utilization Management activities properly - with the right processes in a timely manner.

 

Content for the program will include the following:

  • Utilization Management Definition

  • Level of Care Determinations

    • Use of Interqual ISD criteria

    • Rules for criteria usage

  • Four Main Processes

    • Pre-admission review

    • Admission review

    • Subsequent review/continued stay

    • Discharge review

  • Medicare and Medicaid Conditions of Participation

  • Denial Management

  • Performance Opportunity Tracking System

Target Audience:

This program is designed for registered nurses, chief nursing officers, case managers, nursing managers, quality/performance improvement professionals, utilization managers, and front-line nursing staff responsible for incorporating case management activities in the nursing process.

Learning Objectives:

Learn how to utilize acute care criteria to identify and facilitate patient movement throughout various levels of acute care.

Review the four main processes for effective utilization management.

Learn about required utilization management activities as specified in Medicare’s Conditions of Participation.

Learn strategies for more effective management of denials.

Learn a process for identifying and reporting level-of-care and ancillary service opportunities for improvement.

 

 

 

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