Module A: Dynamics and Structure

CE Credits: 1.5

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This module lays out the basics of utilization management, and how a case manager can execute that process in an ever-changing environment of healthcare. First, it looks at the basic process—the evaluation of the medical necessity, appropriateness and efficiency of the use of healthcare services, procedures and facilities as a means of approving medical coverage. It highlights the process of UM in part by looking at the system it replaced, utilization review, which looks backward in a sense, evaluating how effective services were before approving coverage. UM, on the other hand, looks forward; the module then explores how the team working along the continuum of care can help determine the best care for the patient, a factor needed to ensure payment for the hospital.

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Learning objectives: After completing this module case managers will be able to:
» Describe the changing landscape of healthcare delivery and utilization
» Review the definitions of CM and UM
» Discuss the need for effective CM communication across the continuum of care
» Identify the components of traditional UR and contemporary UM
» Describe the organizational culture and essential elements for successful UM

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Advance your professional practice: Case managers are often the main liaisons between patients and payers. When we understand how to make the most of the available resources for patients, while also addressing the hospital’s financial needs, we can offer a win-win for our patients and healthcare organization.

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Improve organizational performance: Knowing how to work within the regulations and guidelines of the healthcare industry is vital to our whole team and the hospital because it helps improve processes and clinical outcomes, reduce costs and prevent waste.