Course Code: REL-ACU-0-UTMRP
Hours: 1
Type: Online Course
Content Expiration Date: 12/31/2029
Learning Objectives:
Recall the function of utilization review (UR) and the structure of the utilization management (UM) committee.
Apply the concepts of the UR process, including how to use UR criteria to determine medical necessity.
Identify the common types of utilization reviews and their key features.
Outline:
Section 1: Introduction to the Review Process
Overview of Utilization Review (UR)
What Are UM and UR?
Medical Necessity
UM Committee
UM Plan
Knowledge Check
Key Takeaways
Section 2: UR Criteria and Process
Overview of the UR Process
UR Criteria
The Utilization Review Process
The Four Core Elements of the UR Process
Quality of Documentation
Physician Advisor Referrals
Severity of Illness (SI) and Intensity of Services (IS)
Knowledge Check
Types of Reviews
Regular Reviews
Focused Reviews
Concurrent Review
Retrospective Review
Prior Authorization
Process for Payer-Requested Review
Managing Incomplete Reviews
Denials
Peer-to-Peer Review
Appeals
Levels of Appeals for Medicare
Program Integrity
Knowledge Check
Key Takeaways
Section 3: Conclusion
Course Summary
Course Contributor
Resources
References
Subject Matter Expert: Sarah Hunter RN, SCRN, CNRN, CMSRN
Ms. Hunter is a SME writer at Relias. Her area of expertise is neuroscience nursing, medical-surgical nursing, and thoracic surgery. Ms. Hunter has worked at the bedside for 9 years in acute care and intermediate care at a large community hospital in North Carolina. She also served as chair of the hospital's shared governance council for Nursing Quality Improvement. She has a Bachelor of Arts and an Associate Degree in Nursing. Ms. Hunter is a Stroke Certified RN, Certified Neuroscience RN and a Certified Medical-Surgical RN.
Target Audience:
The target audience for this course is: Care and Case Managers; Nursing Personnel; in the following settings: Ambulatory Care, Hospitals: Acute, Hospitals: Critical Access (CAHs).
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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.