Utilization management (UM) is the evaluation of medical “necessity” or “appropriateness” of health care services and/or procedures dependent on evidence-based clinical documentation. In addition, UM analyzes the efficiency of use, for health care services and its facilities under the provisions of a specified health benefit plan (Stricker, n.d.).
In essence, utilization management is the collection, assessment and monitoring of all healthcare services provided to a patient, based on their individual clinical diagnoses: ensuring each patient receive the right services at the right time for the right duration.
Utilization Management Director
Role Overview
The utilization management (UM) director is considered an upper level management position
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Educational Requirements According both Career Builders and Indeed, most organizations require at minimum, a bachelor’s degree in nursing, health care administration, health information management or other health related field. However, most organizations prefer applicants to possess a master’s degree with either a case management certificate (CCM/CMC), Health Care Quality and Management (HCQM) certificate, Certified Professional in Healthcare Quality (CPHQ) certificate. Additional, on average, most organizations prefer 7 + years UM experience, including 5+ years in management and 10+ years experience in their chosen health care field. However, I would like to note, an overwhelming majority of employment opportunities for UM directors required a minimum of 10 years nursing experience.
Responsibilities
A utilization management director should have an extensive knowledge and understanding of current healthcare concepts, procedures and practices. The UM director should be considered as an expert resource and consultant; providing design, development, implementation, and continual monitoring of current medical policies and
The government controls and regulates healthcare somewhat because healthcare organizations are in a position to take advantage of the elderly and sick so there are regulations that protects them. It seems as though healthcare facilities are being paid less for their services today. Some critical measures for the survival of a healthcare organization are to optimize performance and quality. Finding system-wide efficiencies and cost reduction healthcare will help. In order to get better and keep high quality and performance while still raising reimbursements, it is necessary and important to involve doctors with the ideas and plans for any management strategies.
Over the past few years, the health care service has seen many changes. The Affordable Care Act, for example, creating more insurance in order to care for the indigent and people in the most need of help. Health care is a very essential and necessary element of an individuals lives. The methods and preparation that is needed in order to provide adequate and efficient patient care to all is very critical and sometimes specific. The health care organization has ventured from focusing on input management to focusing and improving output management (White, 2011).
Hospitals recognized the need for the case management model in the mid 1980’s to manage the lengths of stay of hospitalized patients and the treatment plans (Jacob & Cherry, 2007). In 1983, the Medicare prospective payment program was implemented which allowed hospitals to be reimbursed a set payment based on the patient’s diagnosis, or Diagnosis Related Groups (DRG), regardless of what treatment was provided or how long the patient was hospitalized (Jacob & Cherry, 2007). To keep the costs below the diagnosis related payment, hospitals ...
When one examines managed health care and the hospitals that provide the care, a degree of variation is found in the treatment and care of their patients. This variation can be between hospitals or even between physicians within a health care network. For managed care companies the variation may be beneficial. This may provide them with opportunities to save money when it comes to paying for their policy holder’s care, however this large variation may also be detrimental to the insurance company. This would fall into the category of management of utilization, if hospitals and managed care organizations can control treatment utilization, they can control premium costs for both themselves and their customers (Rodwin 1996). If health care organizations can implement prevention as a way to warrant good health with their consumers, insurance companies can also illuminate unnecessary health care. These are just a few examples of how the health care industry can help benefit their patients, but that does not mean every issue involving physician over utilization or quality of care is erased because there is a management mechanism set in place.
Health care management professionals working in the lower level position may have limited or no education so they either have to go to college for advancement or stay in the same position throughout their life.
Buchbinder, S.B., & Shanks, N. H. (2007). Introduction to Health Care Management. Sudbury, MA. Jones & Bartlett Publishers. Performance Improvement in Health Care. 5, 81-135.
Three areas that define the provisions of comprehensive health care services and are commonly used for utilization monitoring and control are gatekeeping, case management, and utilization review (UR). Gatekeeping is used by HMOs where each member designates a primary care provider (PCP) that is responsible for coordinating all care services needed for the enrollee in a managed care plan. Case management involves an experienced health care professional with knowledge of available health care resources. `Case management services are designed to identify spec...
A bachelor’s degree is required for this role, however, a master’s degree is recommended. The NI assumes both the technical roles which closely involve the design of information systems, and the less technical positions, such as project manager for the adoption of a new application or trainer of the users. They bring institutional knowledge and experience to the table when applications are designed to meet the needs of the users (AMIA, 2015). Overall, the application of nursing informatics knowledge is empowering and NP, NE, and NA require it in achieving patient centered
I had the opportunity to meet with Dee Laguerra for a few hours and learned so much about the Medical records side of our facility and its impact on healthcare organization. As Director of Health Information Management (HIM) she is responsible for many aspects of managing the medical record; which is a legal document. I did not realize how complex this department is and how vital this department is to the legal and financial position of the organization. Dee’s position as director is the responsibility for the collection, organizing, scanning, and completions of the medical records in a timely matter after the patient is discharged. The reason for the timeliness of scanning the medical records is for the preparation for the coders to review all the charts to code for insurance billing. The time requirement for th...
But for those who want to be in a higher management position like myself you will never a bachelor’s degree. You’ll also be required for more education depending on the type of Practice manager you want to be if it’s a special manager you want to be like a Physician practice manager you’ll have to take the certification test. Of course internship will be required of me in order to meet the requirement and be qualified as a Practice manager.
There are many educational requirements for this field. Credentials include, human resources in healthcare administration, leadership and ethics in healthcare
...that can be conducted by other qualified professionals which will provide them with more time to devote to patient care. This use of HIM professionals in the UM process establishes a new area that organizations can capitalize on to improve the patient care.
You can become a Healthcare Administrator by obtaining your Bachelors of Science in Healthcare Administration degree. It takes about four years to complete the courses and is equal to 180 credits for the classes at Kaplan University. If I decide to manage a nursing home facility, I will need to pass the licensing exam for nursing home administration after I have received my degree in health care administration. Some courses that are taken include Healthcare Policy and Economics, Finance for Health Care, and Medical Office Management. Many further their career and continue their education on to receive a Master’s. Thus opening more job options.
Prerequisites: These are the characteristics of a health care provider like competency, dedication towards work, social skills, and understanding self and others values and beliefs.
People that are interested in this line of work like activities that include leading, making decisions, and business. They have integrity, have leadership qualities, are able to take initiative, and are dependable people that can handle a high stress level. I learned from my results that I am more of social person and the interest profile would recommend me doing something that helps people or being of service to people, which I feel that I am able to do in this profession. I also was ranked highly in enterprising which means that I like persuading and leading people which I think is a great asset as well for being able to run a major facility and work with many different people this seems like these would be essential traits for this position. Further research has lead me to find a few more ideal characteristics to have. One being able to communicate clearly and respectfully with patients, customers, industry leaders, and hospital workers. Second, leadership is important. A healthcare administrator needs to have the ability to create a shared vision for and inspire the entire work staff/team. You also have to have a good knowledge of healthcare. Someone that is able to stay on top of healthcare system policies, the latest innovations in healthcare technology, and the ever changing political landscape of the industry. (Healthcareadministration.com,