Goal and Learning Outcomes

The goal of this continuing education program is to provide nurses with the basic principles of utilization management (UM). After studying the information presented here, you will be able to:
  • Describe how and why the utilization review (UR) process was created
  • Discuss the impact of diagnosis-related groups on the healthcare industry
  • List the basic elements of the UM process
  • Compare and contrast UR and UM
  • Describe the role of the UM committee in an acute care hospital
  • Discuss the role of physician advisors in the UM process
  • List two types of criteria in common use and explain how they differ
  • Explain the process for physician advisor referral
  • List five types of review and discuss when each is used
  • Differentiate between the clinical nursing process and the UM nursing process
  • Describe the kinds of information that are integral to determining medical necessity and appropriateness of care
  • Define clinical guidelines and explain how they are used
  • Describe the factors determining a patient’s length of stay
  • Discuss prior authorization and how it affects length of stay
  • Differentiate between the different parts of Medicare
  • Explain who is eligible for Medicare
  • Define and discuss diagnosis-related groups
  • Explain the role of quality improvement organizations
  • Describe the differences between health maintenance organization, preferred provider organization, and point-of-service plans
  • Describe two characteristics of independent provider associations
  • List types of HMOs and explain their differences
  • Explain fee-for-service insurance plans
  • Differentiate between TRICARE, military, and Veterans Health Administration coverage
  • List five alternative sources of funding for patients with no health insurance coverage
  • Explain the term “coordination of benefits”
  • Explain how the utilization process functions in a mental health/chemical dependency setting
  • Describe how the utilization process functions in a home health setting
  • Explain how the utilization process functions in an external review organization
  • Describe the threats to confidentiality in today’s healthcare industry
  • Define discovery law and explain how it affects UM
  • Explain the impact of patient elopement on reimbursement
  • Describe the impact of the Health Insurance Portability and Accountability Act on UM
  • Explain how quality indicators are used
  • List three types of financial indicators and explain why it is important to monitor them
  • Define “resource utilization”
  • Describe the role of the review professional
  • Identify competencies of a UM nurse
  • Describe ways to prepare for a UM career

Course Authors

Accreditation Information


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.

Unless stated above, the planners and authors of this course have declared no relevant conflicts of interest that relate to this educational activity. Relias LLC guarantees this educational activity is free from bias.

Please see CE Course Instructions to learn how to earn CE credit for this module.

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