This document defines and outlines utilization management (UM). UM is the process of assessing healthcare services to determine if care is medically necessary, appropriate, efficient, and meets quality standards. The purposes of UM include ensuring effective and efficient use of resources, continually assessing access and quality of care, and complying with regulations. Goals are promoting high quality, cost-effective care and making decisions based on medical necessity. Types of UM include prospective review before care, concurrent review during care, and retrospective review after care. The structure involves UM committees and councils. Nurses' duties in UM include concurrent review, precertification, monitoring staff, discharge planning, and maintaining accurate records.

1. Utilization management
By / Mahmoud Shaqria
‫شقريه‬ ‫محمد‬ ‫محمود‬

2. Outlines:
1-Definition of utilization management
2-Purpose of a utilization management
3-Goals of UM
4-Objectives OF UM
5-Types of UM
6- Utilization Management Structure
7-Duties and Responsibilities of nurse in UM

3. Definition of utilization management:
Utilization management (UM):
Is a process for assessing the delivery of
healthcare services to determine if patient care is
medically necessary , appropriate , efficient and
meets quality standards.
UM in hospital setting includes the formal review
of hospital inpatient or observation status patients
on a prospective, concurrent , or retrospective
basis.

4. Purpose of a utilization
management
1-to assure the effective and efficient utilization of hospitals,
physician providers, facilities, case management services and
social services.
2- to continually assess and improve as necessary, member
access to care as well as quality of care available to members.
3-to comply with local and regional healthcare delivery
regulation and accreditations .
4-under or over utilization of services is not occurring.
5-services are medically necessary, delivered at an appropriate
level of care , place of service and consistent with

5. Goals of UM:
1-Promoting, monitoring, and evaluating the delivery
of high quality, cost effective medical and behavioral
health or Substance Use Disorder (SUD) care services
for all members
2. Making UM decisions based on medical necessity,
appropriateness, and availability of resources and
benefits

6. 3. Ensuring confidentiality of personal health
information
4. Monitoring and improving practitioner and
member satisfaction
5. Connecting members to case management
services when appropriate

7. Objectives OF UM:
1. To provide consistency during the UM review and
decision making process
2. To ensure that medical and behavioral health care and
SUD services are medically necessary, appropriate, and
provided in the most cost-effective setting.
3. To facilitate communication and collaboration among
members, practitioners/providers and the organization to
support cooperation and appropriate utilization of health
care benefits.

8. 4. To provide information to practitioners regarding
utilization management updates and activities.
5. To identify high utilization of resources and implement
appropriate case management activities.
6. To render timely determinations and issue timely
notifications.
7. To identify and initiate process improvement activities
to enhance overall quality improvement.
8. To assist with discharge planning and transition of care
issues.

9. Types of UM
1-Prospective review:
*Is conducted at the onset of a service or treatment and is also
referred to as precertification or prior authorization. This
review is performed before care is rendered in order to
eliminate or reduce unnecessary services.
*Prospective review may have the impact of not authorizing or
limiting care that had been recommended by the evaluating
provider(s).

10. 2-Concurrent reviews:
*performed during the course of treatment or
episode of care.
*Intervention occurs at varied intervals and
may encompass case management activities
such as care coordination, discharge planning,
and care transitioning.
*Concurrent review may have the impact of
curtailing an existing episode of care.

11. 3-Retrospective review :
*Is conducted after the service has been
completed and assesses the appropriateness of
the procedure, setting, and timing in
accordance with specified criteria.
*Such reviews often relate to payment and
may result in denial of a claim.
*Financial risk for a retrospective denial is
often borne by the provider.

12. Utilization Management Structure:
1-Utilization Management Committee:
*The UM Committee is comprised of the Chief
Executive Officer “CEO” , Chief Compliance
Officer “CCO,” and the Participants’
*Utilization Management staff appointed by the
respective Participant CEO/Executive Director
(ED).
*All Participants shall have equal representation on
this committee.
*Retain and delegated UM functions are outlined in

13. 2-Operations Council:
*The Operations Council reviews reports concerning
utilization and quality improvement matters as
identified by the Quality Improvement Council (QIC)
and UM Committee and makes recommendations for
regional planning and improvement to the Chief
Executive Officer “CEO”.
*The Operations Council shall be comprised of the
CEO of each Participant.

14. :Duties and Responsibilities of nurse in UM
1-Concurrent review of patient’s clinical information for efficiency
2-Ongoing review of precertification requests for medical necessity
3-Monitor the activities of clinical and non-clinical staff
4-Coordinates patient’s discharge planning needs with the
healthcare team
5-Employ effective use of knowledge, critical thinking, and skills to:
*Advocate quality care and enhanced quality of life
*Prevent patient complications during hospital stay
*Advocate decreased hospital stay when appropriate

15. 6-Maintain accurate records of all patient related
interactions
7-Prepare monthly patient management and cost
savings report
8-Work in an intensive, fast-paced environment with
minimal supervision
9-Ability to stay organized and interact well with others
in any situation
10-Provide daily updates to Manager of Utilization
Management for review

16. Thank you…..