10 Tips for Successful Hospital Utilization Management: From Foundation to New Trends

Why Should You Attend:

Utilization management is a challenging process. Payers are demanding and are doing everything they can to deny payment through denial of medical necessity. Case management leaders struggle with determining the best model of case management, the optimal roles and the place where utilization management should reside—as a functional role of a bedside RN case manager or separate from that role.

Denial management requires critical thinking by RN case manager and can be both time-sensitive and time-consuming. Payer rules and regulations drive the need for timeliness of the UM process. Rules and regulations by different payers are challenging to both understand and operationalize.

The relationship of physicians to the UM process is critical. Engaged and effective attending physicians, consulting physicians and physician advisors are key in a successful case management program.

Areas Covered in the Webinar:

• Definition of utilization management
• Essential case management department roles related to utilization management
• Utilization management and billing and reimbursement
• Rules and regulations affective UM processes
• Best practice in clinical reviews
• The best place to manage UM: bedside or separated from bedside RN case manager function (integrated and triad models of UM)
• Appropriate UM documentation
• Physician utilization management
• Physician advisor role in UM
• Incorporating UM into your daily routine
• Managing denials before they happen: denial and appeal key functions
• The appeals coordinator
• UMs future: Artificial Intelligence

Who Will Benefit:

• Directors of Case Management
• RN Case Managers
• Social Work Case Managers
• Directors of Finance
• Directors of Social Work
• Physician Advisors
• Chief Medical Officers
• Any Executive Responsible for Case Management

Bev Cunningham
Consultant, Case Management Concepts LLC

Bev Cunningham, MS, RN, ACM is a founding partner of Case Management Concepts, LLC. She has a 25-year deep working knowledge of case management with specific expertise in denials management, patient flow and the role of the Case Manager and Social Worker in the Case Management process. Bev is also a certified case manager with the American Case Management Association. She has served as a Commissioner on the Commission for Case Management Certification and is a fellow with the Advisory Board. Bev is also the former Vice President of Resource Management at Medical City Dallas Hospital.

She has co-authored a book for hospital case managers—Core Skills for Hospital Case Managers and has written the utilization management chapter in the past two editions of CMSA’s book, Core Curriculum for Case management.

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