Utilization Review in the Case Management Field.
Just consider utilization review the systematic way you match patient care with clinical criteria, payer policy and best-practice principles to assure care is appropriate, timely and noted.
Your role as a case manager is to review utilization of services to determine the medical necessity, level of care, and the duration of treatment. It safeguards patient safety through the use of evidence-based medicine and is good stewardship of financial resources by avoiding unnecessary services. Utilization review also manages and directly connects clinical necessity to administrative necessity so that the treatment plan is both patient focused and compliant.
You will run into three types of UR: prospective review (which determines if service is needed before it happens, a.k.a. prior authorization); concurrent review (which takes place while patient care occurs, inpatient or outpatient hospital services are under way) to track progress and discharge planning; and finally retrospective review, which evaluates the care that was delivered after it has been provided to check appropriateness and opportunities for improvement.
As a case manager in utilization review, you'd be performing clinical assessment, overseeing documentation, coordinating patient care and working with providers and payers. You compile and review medical records, apply evidence-based criteria to make or support decisions on both approvals and denials, present your cases to the members of the care team and help them through all necessary approval or appeals. Proactive case managers will prepare for discharge, set up community services, and avoid the delay effect on length of stay.
Practical approaches to adopt involve a timely and iterative assessment process, the application of standardized criteria and decision support tools, consistent documentation in describing plans of care concisely and comprehensively, as well as preemptively communicating with payers for authorization advancement. When denials are made, you write focused appeals giving clinical reasons and backing for patient long-term interests.
Quantify the value of your work within utilization review, including such measures as authorization turnaround time, approval/denial rates, average length of stay, readmission rates and cost per case. Those measures enable you to streamline operations, prove your value to stakeholders and enhance patient outcomes as care aligns with payer expectations.
By weaving utilization review into your care management practices, you achieve the balance of quality vs. efficiency – with a strong voice for the patient and defensible, timely clinical decisions based on both what’s best for patients and payer expectations.”
