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This course has been approved for 8 clock hours by the Commission on Case Manager Certification from January 1, 2006 through December 31, 2008.

The purpose of this course is to provide nurses with the basic principles of utilization management.

When you complete this course, you will be able to:

• Define utilization management and explain its origins and purpose.
• Describe the role of the utilization review committee.
• Identify criteria used in the utilization process.
• Name five types of review and discuss when each is used.
• Compare the nursing clinical process to the nursing utilization process.
• Explain how patient care pathways are influential in the utilization process.
• Differentiate between Medicare and Medicaid.
• Describe HMO, PPO, and IPA models.
• Identify two areas within UM that are affected by the Health Insurance Portability and Accountability Act (HIPAA).
• Explain the managed care concept and describe how it affects utilization management.
• Identify three types of data collection that are significant for measuring outcomes in the utilization process.
• Identify the principal components of criteria for admission, continued stay, and discharge in the mental health and chemical dependency setting.
• Discuss the role and responsibilities of the utilization professional in the skilled nursing, home health, and external review settings.
• Identify the legal responsibilities of the utilization professional.
• List five characteristics of a successful reviewer.