Goal and Learning Outcomes

This course has been approved for 8 hours by the Commission on Case Manager Certification for 1/15/10 through 12/31/10, 2011, 2012, 2013, 2014, and 2015 and for 6 hours for 2017.
The goal of this utilization review continuing education program is to provide nurses with the basic principles of utilization management. After studying the information presented here, you will be able to:
  • Define UM and explain its origins and purpose
  • Describe the role of the UR committee
  • Identify criteria used in the UM process
  • Name 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 various managed care models
  • Identify two areas within UM that are affected by the Health Insurance Portability and Accountability Act
  • Explain the managed care concept and describe how it affects UM
  • Describe 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
  • Describe the legal responsibilities of the utilization professional
  • List five characteristics of a successful reviewer

Course Authors

Accreditation Information


In support of improving patient care, OnCourse Learning (a Relias LLC company) 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.

For Florida professionals:

Reports to CE Broker imageThis course completion will be electronically reported to CE Broker as required per Florida Statute 456.025(7). Click here to view your CE Broker transcript and check the status of your CE requirements with a FREE 7-day CE Broker trial subscription. It may take up to 24 hours for the course to appear on your CE Broker transcript.

It is now required that all CE is completed and reported to CE Broker before you renew your license. When you complete continuing education with us, OnCourse Learning will report your hours for you.

Read more about the new license renewal process at AreYouRenewalReady.com and claim your free Basic Account in CE Broker to see what has already been reported for you.

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