Nursing Beyond the Bedside – Utilization Management and Utilization Review

Utilization Management (UM) is one of the many nontraditional bedside jobs a nurse can pursue. In this article, we will look at what utilization management is and how to move into this position. 

Defining Utilization Management and Utilization Review

URAC (formerly the Utilization Review Accreditation Commission), a nonprofit organization promoting healthcare quality by accrediting healthcare organizations, defines utilization management as “the evaluation of the medical necessity, appropriateness, and efficiency of the use of healthcare services, procedures, and facilities under the provisions of the applicable health benefits plan.” Utilization management describes proactive actions such as discharge planning, concurrent review, and precertification. 

Utilization Review (UR) is similar to utilization management but where UM is proactive, UR is retrospective as it is the review of cases after healthcare services have been carried out.

Utilization management ensures services provided are medically necessary and provided at the appropriate and least costly level of care. Although many think that this is only a concern for the payer source, in reality, it is the job of all nurses. As patient advocates, nurses understand that undergoing an unnecessary service, test, or treatment is not in the best interest of the patient. Nurses also understand that most patients will have some degree of cost-sharing, whether in the form of copay, coinsurance, deductible, or benefit maximum. Ensuring that costs are contained ultimately benefits the patient as well as the payer source. 

There are three main types of utilization management: prospective, concurrent, and retrospective (which is technically utilization review).

Prospective review or precertification is done prior to the elective admission or procedure to ensure the requested service is necessary, meets criteria for coverage, and is at the appropriate level of care.

The concurrent review includes continued stay review and is conducted as the care is occurring. This includes reviews for admissions that were not precertified, as well as to extend the care that was pre-certified. Concurrent reviews are done to ensure the client is receiving the correct care in a timely and cost-effective manner.

The retrospective review is done aftercare has already occurred. This can occur when precertification was required but not obtained, such as in an emergency situation, or as an audit.  

How to get a Utilization Management Position

Utilization Management builds on the skill set of the clinical nurse. A firm clinical background is a must and most employers want 1-2 years of recent acute care hospital experience when hiring a UM or UR nurse. In addition to the clinical background, UM and UR nurses must understand insurance principles, levels of care, and care settings. And finely nurses transitioning into this field must learn and understand the UM Process. Yes, just like nursing has the nursing process UM has a process. 

In addition, there are tools used by Utilization Managers such as MCG and Interqual which use evidence-based criteria to determine if medical necessity is met. Most employers use this type of software and hire those who have experience with using one of these platforms. The problem is, you can’t get training and experience with MCG unless you work for an employer who uses MCG and you use it in your job. 

It’s a Catch-22 of needing MCG training to get a job, but being unable to get the job unless you had MCG training.

For years there was no way to receive training on MCG software unless you worked for a company that utilized the software and you used it in your role. Nurses who wanted to enter UM/UR either didn’t apply for jobs that required or preferred MCG training or competed with 100’s of other unqualified applicants hoping there would be no qualified applicants and they would get a lucky break. There was no way to get the training on your own to stand out from the sea of applicants.

So, Case Management Institute partnered with MCG to bring you the first and only Utilization Management and MCG training course outside of an employer. That’s right! If you want a UM or UR job and don’t have MCG experience, this course if for you. 

In addition to the valuable MCG training, this course includes instruction on insurance principles, levels of care, care settings, and the UM Process.

And to make it even sweeter, after completing Case Management Institutes Course students are eligible to sit for MCG Certification! This really helps you to stand out among the 100’s of applicants for a coveted Utilization Management or Utilization Review position.

If you are interested in working in Utilization Review or Utilization Management you can learn more about this course at the Case Management Institute website

deanna cooper gillinghamDeanna Cooper Gillingham, RN, CCM is a leader in case management with over a quarter-century experience in healthcare as a Registered Nurse and Case Manager. She is CEO and co-founder of the Case Management Institute, and leader and co-founder of the Case Managers Community, a group of over 10,000 committed case managers. From there she hosts the popular Case Managers Community Saturday morning FB Lives.

In addition to her own books, CCM Certification Made Easy: Your Guide to Passing the Certified Case Managers Exam and Foundations of Case Management (Available 2020), she has contributed to other works including Second Acts, Stepping Up to Certification, and Case Management Salary and Trends Survey.

Deanna educates and inspires through both live and online presentations. Her live speaking has included hosting the Case Managers Cruise for 3 years and co-presenting NNBA Pre-Conference Case Management and Patient Advocacy: Career Paths for Nurses Who Want to Move Beyond the Bedside. Her online presentations include Successful Study Strategies for the CCM Exam, Test Taking Strategies for the CCM Exam, and Everything You Need to Know About Case Management As a Career Option for Nurses.