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 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 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.