Quality Series: Utilization Management

Course overview

Efforts to reduce costs in healthcare encompass a host of strategies, including evidence-based clinical guidelines for high-quality care. Additionally, the use of a lower level of care and outpatient services can result in shorter inpatient acute care stays. Utilization management (UM) personnel conduct reviews to identify the appropriate level of care for patients using evidence-based practices and medical necessity criteria. The reviews also identify avoidable and unavoidable delays that may impact the delivery of care. Clinicians performing utilization reviews collaborate with the multidisciplinary team daily to address patient needs. Nurses working in the acute care setting need to understand the criteria used for utilization reviews and the importance of their role in documenting and communicating patient care.