#utilization review

Many of you touch case management nursing in some fashion on your health care journey and the more you know about it, the easier it becomes for you to navigate some of these complex systems with a bit less trepidation.

Case Management Nursing - helps communicate between clinical and environment resources to ensure your care is a well oiled cared that marries the best of both worlds, clinican and clerical. Your case manager reviews your health history, social support and financial challenges to create a care plan tailored to meet your needs and goals. This evaluation, in turn, provides precise interventions in order to decrease the occurrence of complications and minimize hospital readmission.

When you encounter transitions—admission, discharge or transfers between facilities— Case Management makes sure those handoffs are seamless. Your nurse works with doctors, therapists, pharmacists and payers to check orders, schedule follow-up visits and confirm D.M.E. items or home health services. This coordination can also help you to avoid gaps in treatment and reduce the risk of harm during recovery at home or elsewhere.

Your case management nurse serves as your advocate, speaking up for you concerning decisions for you care. You receive easy-to-understand explanations of diagnoses, available treatment and limitations of coverage to help you make informed decisions. That case manager also assists you in getting connected to community programs, transportation or financial help if something outside of your doctor’s care is going to get in the way of your health plan.

Work done in Case Management includes utilization review and quality monitoring, which have a real impact on your experience. Your nurse checks care against clinical guidelines to make sure the services you get are timely and necessary, with no duplicate tests or too many days in the hospital. This lack of attention benefits you in terms of your clinical outcomes and the cost effective use of healthcare.

If you have a chronic condition, case management provides ongoing assistance. Your nurse assists in coordinating specialty care, managing medications and self-care education to improve symptom management and functional status. With periodic follow-ups and monitoring of outcomes, adjustments can be swiftly made to your plan when your requirements change.

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.

A medical review company supplies more than a second opinion. The unbiased nature of a medical review company is critical not only to the bottom dollar, but to the final result. Too often, patients think they are just numbers in a file or bits of information in a computer program. The maligned image of an insurance company’s automatic denial of claims without really understanding the patient’s…

Expenses in health care can get out of control, and you could be hit with a pile of bills and the uncertainty about whether they’re necessary.

Utilization Review: Utilization review is a review of how your covered health care services are used to make sure they are appropriate, necessary, and provided in the most cost- effective setting. In case management, this review is used to coordinate your plan of care and an assessment of the medical necessity of procedures, admissions and continued stay. That means you get the treatments you need, when you need them, eliminating unnecessary tests and hospitalizations that can jack up costs without benefiting your health.

Your certified case manager provides professional support and acts as your advocate in respect to your care. Your case manager collaborates with your health care providers, including insurance companies and others to discuss your treatment options on an ongoing basis. This collaborative way of working minimizes the duplication of services, and provides alternative opportunities for care settings (e.g., outpatient care being preferred to inpatient — often less costly and just as effective).

One of the primary ways utilization review cuts costs is by identifying potentially unnecessary procedures as early as possible. For instance, if a diagnostic test or a surgery is recommended for you, the care managers would check whether these conform to the clinical guidelines and your medical history. If other treatments can provide better value, you might be shepherded toward those first, perhaps staving off more expensive interventions.

This process has a lot to do with your involvement. By discussing your symptoms, concerns and preferences with your case manager and health care team, they can help you make the review relevant to you. This personalized methodology is the only way to guarantee you are both protected from overpaid procedures and also knowledgeable about your compliant end's heath.