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
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
Speakers
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.
