Utilization Management Workshop Series: Best Practice Applications for the Hospital Setting Part 2 (W4017)

This is a recording of a live webinar delivered on May 23, 2024.

Utilization management was the first role applied in acute care case management models. It was first known as utilization review but has evolved into something much more comprehensive. Today it encompasses elements of resource management as well as denials management. It has become an important aspect of the hospital revenue cycle. Physicians, both the practicing physician and the physician advisor are, at times, left out of this important process but must be included in any contemporary case management model that includes utilization management.

This four-part series will introduce the role of utilization management as it applies to today’s contemporary case management models. These webinars will focus on understanding the utilization management processes for Registered Nurses (RN) assigned to this role. With the changes in case management department models, the series will also focus on the role of those RN case managers, social work case managers, and other department staff who collaborate with the role of the RN utilization manager. Also included in the webinars will be an example of the day in the life of a utilization case manager.

Challenges for implementing the utilization management process will be addressed. Included will be best-practice suggestions for your role of utilization management with tips and strategies for stream-lining the process and making it as efficient as it can be. Additionally, discussed with be the importance of utilization management collaboration with physicians, the interdisciplinary team, case management department peers, and payers.

Lastly, documentation of utilization management will be discussed. This will include documentation in the medical record and the role of electronic utilization management software.

Bev Cunningham, RN, MS

Bev Cunningham has been a Partner and Consultant with Case Management Concepts, LLC, since its inception. Before moving to full-time consulting, Bev served as the Vice President, Resource Management at Medical City Dallas Hospital. Her areas of responsibility included Case Management, Health Information Management, Patient Access, Solid Organ Transplant, and Transplant Financial Services. As a previous Clinical Assistant Professor for the Master of Nursing Program at the University of Oklahoma, Bev coached students in their clinical practicums.

Bev is a well-known speaker in the Case Management field. Involved in the development of case management for over twenty-five years, her areas of expertise include the role of the case management in the revenue cycle, compliance for case management departments, the role of the physician advisor and effective denials and appeal management. She has served as a Commissioner on the Commission for Case Management Certification and is a Fellow with the Advisory Board. She has achieved ACM certification by the American Case Management Association.

Toni Cesta, Ph.D., RN, FAAN

Toni G. Cesta is a founding partner of Case Management Concepts, LLC, a consulting company that assists institutions in designing, implementing, and evaluating case management departments and models, educational programs, and onsite support for leadership and staff.

She has been active in the research and development of case management for over 25 years. Her research has included two funded studies measuring the effects of a case management model on congestive heart failure and fractured hip patient populations, with measures of patient satisfaction, quality of life, and short- and long-term clinical perceptions and outcomes.

The speakers have no real or perceived conflicts of interest that relate to this presentation.

At the conclusion of this session, participants should be able to:

Explain the role of utilization management for the RN case manager.

Recite best practices for the processes used to perform the utilization management role.

Discuss the compliance requirements for utilization management.

Record medical necessity criteria into the clinical review process.

Recall the denial and appeal process.

Identify clinical review examples to apply the information learned.

The Georgia Hospital Association Research & Education Foundation is an approved provider of nursing home administrator credits as a professional trade association in long term care under Ga. Comp. R. & Regs. 393-13-.02, (1) (a). Approved for 8 contact hours.

By attending Utilization Management Workshop Series: Best Practice Applications for the Hospital Setting offered by Georgia Hospital Association, participants may earn up to 8 ACHE Qualifying Education Hours toward initial certification or recertification of the Fellow of the American College of Healthcare Executives (FACHE) designation. Attendees who wish to have the hours applied toward ACHE Qualifying Education credit must self-report their participation by logging into their MyACHE account and selecting ACHE Qualifying Education Credit.

Please complete the course evaluation to earn your certificate of participation.

Contact us at education@gha.org with any questions.