Utilization Management Course

Lesson 1 • The UM Program Structure

Describes how UM departments are organized, staffed, and governed. Clarifies reporting relationships and accountability within a UM program.

Lesson 2 • Core UM Processes Overview

Introduces the three primary review types and their workflow sequence. Sets the stage for deeper exploration in later chapters.

Lesson 3 • What Is Utilization Management

Defines UM, its historical origins, and its position within healthcare operations. Provides the conceptual baseline for all subsequent chapters.

Lesson 4 • Regulatory and Accreditation Framework

Covers the regulatory bodies and accreditation standards that govern UM programs. Connects compliance requirements to day-to-day UM decision-making.

Lesson 1 • Medical Necessity Determination

Defines medical necessity and distinguishes it from experimental or custodial care. Directly supports accurate prior authorization and concurrent review decisions.

Lesson 2 • Introduction to Clinical Criteria Sets

Surveys widely used clinical criteria tools and their intended applications. Establishes why standardized criteria are central to defensible UM decisions.

Lesson 3 • Applying Criteria to Clinical Scenarios

Demonstrates step-by-step application of criteria to real case types. Builds the analytical skill needed for accurate coverage determinations.

Lesson 4 • Evidence-Based Medicine Fundamentals

Introduces evidence hierarchies and how clinical literature informs criteria development. Enables staff to evaluate the strength of evidence behind coverage policies.

Lesson 1 • Urgent Versus Standard Requests

Distinguishes expedited from standard authorization timelines and triggers. Ensures staff meet regulatory turnaround mandates for each request type.

Lesson 2 • Physician Advisor Role in Authorization

Explains when and how physician advisors engage in the authorization process. Clarifies the boundary between clinical and administrative review functions.

Lesson 3 • Prior Authorization Workflow

Maps the complete prior authorization process from request intake to decision notification. Provides the procedural foundation for all authorization work.

Lesson 4 • Applying Criteria in Authorization

Connects clinical criteria application directly to the authorization decision workflow. Reinforces accurate, consistent determination practices under time pressure.

Lesson 1 • Observation Versus Inpatient Status

Clarifies the clinical and financial distinctions between observation and inpatient admission status. Prevents costly misclassification and associated compliance risk.

Lesson 2 • Continued Stay Criteria Application

Applies clinical criteria to determine whether ongoing inpatient care is medically necessary. Directly reduces avoidable days and inappropriate resource use.

Lesson 3 • Discharge Planning Integration

Links concurrent review findings to proactive discharge planning activities. Ensures safe, timely transitions that reduce readmission risk.

Lesson 4 • Collaboration with the Care Team

Describes how UM nurses and case managers partner with physicians and social workers during concurrent review. Strengthens interdisciplinary communication skills.

Lesson 1 • Quality Indicators in Retrospective Review

Uses retrospective data to identify patterns in care quality and utilization. Feeds findings into quality improvement and UM program evaluation.

Lesson 2 • Claims Coordination and UM Alignment

Explains how retrospective review findings inform claims payment decisions. Connects UM determinations to accurate and timely claims processing.

Lesson 3 • Retrospective Denial Management

Covers the process for issuing and tracking retrospective denials. Prepares staff to manage provider disputes and maintain audit trails.

Lesson 4 • Retrospective Review Purpose and Scope

Defines retrospective review, its triggers, and its role in validating prior decisions. Distinguishes it from prospective and concurrent review functions.

Lesson 1 • Member Grievance Handling

Distinguishes grievances from appeals and outlines the grievance resolution workflow. Ensures staff respond to member complaints within required timeframes.

Lesson 2 • Clinical Review of Appeals

Covers how physician advisors and clinical staff evaluate appeal submissions against criteria. Reinforces objective, evidence-based appeal decision-making.

Lesson 3 • External Review and Compliance

Prepares staff to submit cases to independent external reviewers and respond to findings. Addresses compliance obligations when external decisions are binding.

Lesson 4 • Building the Appeal Case File

Describes the documentation required to support a complete and defensible appeal review. Directly reduces procedural denials and overturn risk.

Lesson 1 • Data Collection and Integrity

Covers data sources, collection methods, and quality controls that ensure reliable UM reporting. Accurate data collection is prerequisite to valid analysis.

Lesson 2 • Reporting for Internal Stakeholders

Teaches how to structure and present UM reports for clinical and operational leadership. Connects data output to actionable management decisions.

Lesson 3 • Using Data for Program Improvement

Applies analytical findings to design and evaluate UM process improvement initiatives. Closes the loop between measurement and operational change.

Lesson 4 • Benchmarking and Comparative Analysis

Introduces external benchmarking sources and methods for comparing UM performance. Enables identification of performance gaps relative to industry standards.

Lesson 1 • Aligning UM with Quality Improvement

Integrates UM data and processes with the organization's broader quality improvement program. Positions UM as a driver of clinical quality, not just cost control.

Lesson 2 • Financial Impact of UM Decisions

Quantifies how UM determinations affect organizational revenue, cost, and risk. Enables leaders to articulate UM's financial value to executive stakeholders.

Lesson 3 • Vendor and Delegated UM Oversight

Addresses oversight of delegated UM functions performed by external vendors or health plans. Ensures accountability and compliance across delegated arrangements.

Lesson 4 • Building a High-Performance UM Team

Covers recruitment, training, performance management, and retention strategies for UM staff. Equips leaders to develop and sustain a competent UM workforce.