Utilization management has evolved to be much more comprehensive and encompasses elements of resource management as well as denials management. Physicians are, at times, left out of this important process but must be included in any contemporary case management model that includes utilization management.

This four-part series will introduce the role of utilization management in today’s contemporary case management models. The webinars will focus on the role of RN case managers, social work case managers, and other department staff who collaborate with the role of the RN utilization manager. An example of the day in the life of a utilization case manager will also be shared.

The series will address challenges in implementing the utilization management process and will include tips and strategies for streamlining the process. There will also be an emphasis on the importance of collaboration with physicians, the interdisciplinary team, case management department peers, and payers.

Lastly, documentation of utilization management will be discussed. This will include documentation in the medical record and the role of electronic utilization management software.

Learning Objectives
• Explain the role of utilization management for the RN case manager.
• Recite best practices for the utilization management role.
• Discuss the compliance requirements for utilization management.
• Record medical necessity criteria in the clinical review process.
• Recall the denial and appeal process.
• Identify clinical review examples to apply the information learned.

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