Course Code: REL-PAY-0-SAAC
Hours: 1.25
Type: Online Course
Content Expiration Date: 12/31/2025
Learning Objectives:
Recognize the role that utilization management and utilization reviewers play in driving both cost-effective and high-quality services in the payer setting.
Identify the need for balancing cost and quality in the healthcare industry.
Recall the use of evidence-based practices and medical necessity criteria within utilization management and utilization review.
Outline:
Utilization Management Strategies to Improve Quality and Contain Costs
Section 1: Introduction
About This Course
Learning Objectives
Section 2: Understanding Cost Quality Balance
Cost of Care Measures in the U.S.
Why Are Healthcare Costs So High?
Quality of Health in the U.S.
Opportunity for Improvement
Pay For Performance Model
Brief Overview of Concepts
Review
Summary
Section 3: Utilization Management
What is Utilization Management?
History of Utilization Management
Current Practice in Utilization Management
Utilization Management Team
Utilization Management Baseline Knowledge
Review
Summary
Section 4: Utilization Reviews
Definition of Utilization Reviews
Process for Utilization Reviews
Make criteria available
Apply criteria to patient situations
What Does A Review Accomplish?
How Are Utilization Reviews Completed?
Medical Necessity Defined
Requirements for MNC
MNC as Optimal Care
Clinical Practice Standards
Tools for Utilization Reviews
Sources for Utilization Review Tools
Diagnosis Specific Criteria
Utilization Review Assessments
Focused Reviews
Approvals and Denials
Appeals
Review
Summary
Section 5: Utilization Management Impact to Quality and Cost
Overview
Variances
Functions to Increase Quality and Decrease Cost
Patient and Population Health Impact
Impact of Utilization Reviews
Role of All Healthcare Providers
Healthcare Productivity
Section 6: Conclusion
Course Summary
Course Contributor
Resources
References
Exam and BrainSpark
Subject Matter Expert: Monica Caicedo Orellana, MS, RN, OCN
Monica Caicedo Orellana, MS, RN, OCN, is an SME writer for Relias with over 20 years of acute care experience in nursing. She has served in several leadership roles in the acute care setting, the medical-surgical division, and as a nurse educator. She has mentored nurses in renal and oncology specialties. She has been involved in various institutional committees and quality improvement projects. Monica is passionate about professional nursing standards and fostering an environment of continuous lifelong learning as an instrument to improve patient care.
Target Audience:
The target audience for this course is: Advanced, Intermediate level Social Workers; Case Managers; Nurses; in the following settings: All Healthcare Settings.
Relias Learning will be transparent in disclosing if any commercial support, sponsorship or co-providership is present prior to the learner completing the course.
Relias Learning has a grievance policy in place to facilitate reports of dissatisfaction. Relias Learning will make every effort to resolve each grievance in a mutually satisfactory manner. In order to report a complaint or grievance please contact Relias Learning at support@reliaslearning.com.
All courses offered by Relias Learning, LLC are developed from a foundation of diversity, inclusiveness, and a multicultural perspective. Knowledge, values and awareness related to cultural competency are infused throughout the course content.
To earn continuing education credit for this course you must achieve a passing score of 80% on the post-test and complete the course evaluation.
Course Delivery Method and Format
Asynchronous Distance Learning with interactivity which includes quizzes with questions/answers, and posttests.