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Goal and Learning Outcomes

Utilization management (UM) and utilization review (UR) are often used interchangeably. UM is the umbrella practice for evidence-based, cost-effective care review. However, UR is a secondary, more focused branch that reviews billing aberrancies that are discovered by UM. UM began as a process for Medicare beneficiaries, but it has become a program for all insurance carriers and is present in all healthcare settings. UM and UR can either fall under one department or be separated based on organizational needs. 
The goal of this course is to equip nurses with knowledge of the purpose and key principles of utilization management (UM) in the acute care setting, as well as roles and responsibilities associated with the UM process.

After taking this course, you should be able to:

  • Identify the main concepts of utilization management and utilization review.
  • Discuss functions and tools of utilization management and utilization review.
  • Describe the role of nurses in utilization management and utilization review.

Course Termination Date: Not yet determined

Course Originally Released On: 08/01/22

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