Utilization Management: What Does it Really Mean for Case Management Professionals?

HEALTHCARE Mar 21, 2019 90 minutes
01:00 PM EST 12:00 PM CST 11:00 AM MST 10:00 AM PST

Description:-

Utilization management was the first role applied in acute care case management models.  It was first known as utilization review but eventually evolved into something much more comprehensive. Today, it encompasses elements of resource management and denial management as well.  This program will review the role of utilization management as it applies to today’s contemporary case management models. The Included application will be a best-practice suggestion for your practice with tips and strategies for streamlining the process and making it as efficient as it can be. The required compliance for utilization management processes will also be addressed in this webinar. Lastly, there will be a focus on incorporating the role of utilization management with the other roles of case management:  resource management, discharge planning, and care coordination.

Course Outline:-

  • Business of case management
  • Utilization review and utilization management: the difference
  • Compliance of utilization management
  • Access points for utilization management
  • Types of utilization management
  • Denial management
  • Incorporating utilization management into case management rules and functions
  • Physician relationships: Attending physician, consulting physician, and physician advisor.

Learning Objectives:-

  • Describe the difference between utilization review and utilization management
  • Discuss the best practice utilization management strategies to manage an effective case management department
  • Identify ways in which a strong utilization management process can reduce payment denials
  • Ensure effective physician relationships in the utilization management process.

Why Should You Attend?

With the increased focus on the value of hospital case management, it is imperative that case management professionals understand not only the role of utilization management but how to integrate with other case management roles and functions. Many hospitals are not able to provide a comprehensive didactic orientation program for their new staff. This program will provide that, as it relates to utilization management. This will also be a helpful review and update for seasoned case management staff.

Who Should Attend?

  • Director of Case Management
  • RN Case Managers
  • Director of Finance
  • Director of Social Work
  • Social Workers
  • Hospitalists
  • Physician Advisors
  • Chief Medical Officers.
Presenter BIO

Toni G. Cesta, Ph.D., RN, FAAN

is a founding partner of Case Management Concepts, LLC, a consulting company which assists institutions in designing, implementing and evaluating case management models in the acute care, emergency department and outpatient settings. Dr. Cesta writes a monthly column called “Case Management Insider” in the Hospital Case Management newsletter in which she shares insights and information on current issues and trends in case management. 

Dr. Cesta has held positions as Senior Vice President – Operational Efficiency and Capacity Management at Lutheran Medical Center in Brooklyn, New York where she was responsible for case management, social work, discharge planning, utilization management, denial management, bed management, the patient navigator program, the clinical documentation improvement program and systems process improvement. 

Dr. Cesta has a BS in Biology from Wagner College, a BS in Nursing from Adelphi University, an MA in Nursing Administration from New York University, and a Ph.D. in Nursing Research and Theory Development from New York University. Dr. Cesta is a Fellow of the American Academy of Nursing.

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