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Goals and Learning Outcomes

Efforts to reduce costs in healthcare encompass a host of strategies, including evidence-based clinical guidelines for high-quality care. Additionally, the use of a lower level of care and outpatient services can result in shorter inpatient acute care stays. Utilization management (UM) personnel conduct reviews to identify the appropriate level of care for patients using evidence-based practices and medical necessity criteria. The reviews also identify avoidable and unavoidable delays that may impact the delivery of care. Clinicians performing utilization reviews collaborate with the multidisciplinary team daily to address patient needs. Nurses working in the acute care setting need to understand the criteria used for utilization reviews and the importance of their role in documenting and communicating patient care.

The goal of this course is to educate nurses about the impact of utilization reviews and how they are connected to quality surveillance. 


After taking this course, you should be able to:

  • Describe the components of reviews conducted by utilization management personnel and how common criteria, regulations, and clinical practice standards are used during reviews.
  • Describe how utilization management impacts variances in and quality of healthcare services.

Course Termination Date: Not yet determined

Content Expiration Date: 12/31/24

Course Originally Released On: 09/01/21

Course Authors

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Course Reviews

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Accreditation Information

NURSES

In support of improving patient care, Relias LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Provider approved by the California Board of Registered Nursing, CEP#13791

Disclaimer: Not all courses will provide California Board of Registered Nursing approval. Per California Assembly Bill No. 241, continuing education courses related to direct patient care shall address at least one or a combination of the following:(1) Examples of how implicit bias affects perceptions and treatment decisions of licensees, leading to disparities in health outcomes; or (2) Strategies to address how unintended biases in decision-making may contribute to health care disparities by shaping behavior and producing differences in medical treatment along lines of race, ethnicity, gender identity, sexual orientation, age, socioeconomic status, or other characteristics.

 

CEBroker

Relias LLC reports to CEBroker for the following boards (Provider # 50-1489): Arkansas State Board Of Nursing, District Of Columbia Board Of Nursing, Florida Board Of Nursing, Georgia Board Of Nursing, Kansas State Board of Nursing, Kentucky Board of Nursing, Michigan Board of Nursing, Mississippi Board of Nursing, New Hampshire Board of Nursing, New Mexico Board Of Nursing, North Dakota Board of Nursing, South Carolina Board Of Nursing and West Virginia Board Of Registered Nurses

 

Please check the licenses/certifications section under my account (after logging in) to make sure you have entered a valid license number. This information is required for correct reporting of your course completions to CE Broker.

 

Disclosures

None of the planners/faculty, unless otherwise noted, for this educational activity have relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.