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Goals 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.

The goal of this course is to equip nurses with knowledge of the utilization review process in acute care settings.


After taking this course, you should be able to:

  • Explain the basic concepts and functions of utilization management and utilization review.
  • Recall the process and criteria for completing utilization reviews.
  • Classify various types of utilization reviews.

Course Termination Date: Not yet determined

Content Expiration Date: 12/31/25

Course Originally Released On: 07/01/22

Course Authors

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