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Goal and Learning Outcomes

Utilization reviews (UR) are a function of utilization management (UM) departments and are often performed by nurses. UM is a program with plans, policies, and procedures. Utilization review is a process of the UM program. Both aim to ensure evidence-based, cost-effective care by evaluating medical services to determine if they are efficient, appropriate, and medically necessary (Utilization Review Accreditation Commission [URAC], n.d.). Evidence-based criteria provide objective guidelines to apply during a review to determine if a patient is receiving care at the appropriate level or volume and at the appropriate cost. UR nurses perform a variety of reviews depending on the status of the patient, the timeline of their care, and other factors. Reviews are intended to serve as an impartial appraisal of patient care as it is documented in the medical record.

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.

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



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, New Mexico Board Of Nursing, South Carolina Board Of Nursing and  West Virginia Board Of Examiners For Registered Professional Nurses


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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.