How to Be Utilization Review Case Manager - Job Description, Skills, and Interview Questions

The role of Utilization Review Case Manager has become increasingly important in recent years due to the complexity and cost of healthcare. These professionals are responsible for reviewing medical care and services to ensure that they are necessary, medically appropriate, and cost-effective in meeting the patient's needs. Their decisions have a direct impact on the quality of care and the total cost associated with the patient's treatment.

Utilization Review Case Managers are knowledgeable about insurance plans, medical treatments, and medical billing and coding, as well as current healthcare trends and regulations. By leveraging their expertise, they can help reduce unnecessary spending and ensure that patients receive the highest quality care possible.

Steps How to Become

1. Obtain a Bachelor's Degree. To become a utilization review case manager, you must have a bachelor's degree in a related field such as healthcare administration, health science, or nursing.
2. Obtain Certification. It is important to obtain certification as a case manager from an accredited organization like the Commission for Case Manager Certification (CCMC).
3. Gain Work Experience. It is important to gain work experience in a related field such as medical coding, insurance billing, or health information management.
4. Become Familiar With State and Federal Regulations. Utilization review case managers must be familiar with state and federal regulations related to healthcare, such as Medicare and Medicaid regulations.
5. Develop Professional Skills. Utilization review case managers need strong communication and problem-solving skills to ensure the best care for their patients.
6. Obtain Licensure. Depending on the state, utilization review case managers may need to obtain licensure or certification to practice. Check with your state board of nursing for more information.

The ability to stay up-to-date and capable as a Utilization Review Case Manager is critical to success. Professional development is essential to ensure that knowledge and skills are kept current in order to help provide the best care possible. Staying abreast of changes in the healthcare industry, such as regulatory updates, new treatments, and technology advances, will help Utilization Review Case Managers remain knowledgeable and capable.

a strong network of peers and colleagues can provide support and guidance when facing difficult cases. Finally, staying organized and maintaining accurate records allows Utilization Review Case Managers to effectively review and analyze cases, as well as provide accurate information to patients and their families. By developing new skills and staying informed of changes in the industry, Utilization Review Case Managers can remain competent and effective in their roles.

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Job Description

1. Develop and maintain utilization review protocols and procedures, ensuring compliance with all applicable laws, regulations and standards.
2. Monitor patient care services for appropriateness of care, efficiency of services and cost-effectiveness.
3. Analyze medical records and reports to determine medical necessity of requested services.
4. Perform concurrent reviews to identify potential overutilization or underutilization of services.
5. Collaborate with providers and other staff to develop and implement appropriate care plans.
6. Document all utilization review activities and prepare reports on findings.
7. Monitor post-discharge services to ensure that patients are receiving appropriate follow-up care.
8. Coordinate with other departments to ensure optimal delivery of services.
9. Act as a liaison between insurance companies, providers, patients and other stakeholders.
10. Provide education and training to staff on utilization review processes, procedures and standards.

Skills and Competencies to Have

1. Knowledge of relevant healthcare regulations and standards.
2. Ability to communicate effectively with patients, families, and other healthcare professionals.
3. Ability to review medical records for accuracy and completeness.
4. Ability to evaluate medical necessity of requested services.
5. Knowledge of current medical practices and treatments.
6. Understanding of health insurance policies and procedures.
7. Proficiency in medical terminology and coding.
8. Ability to efficiently manage and prioritize multiple projects.
9. Proficiency in data entry, analysis, and reporting.
10. Understanding of various Utilization Review processes and protocols.
11. Excellent problem-solving and critical thinking skills.
12. Proficiency in computer applications, such as Microsoft Office Suite and other healthcare-related software.

Utilization review case managers are responsible for evaluating patient care needs and determining the best course of action for providing the necessary services. This requires critical thinking, decision-making, and strong communication skills. As a utilization review case manager, one must be able to analyze clinical data, assess patient outcomes, and negotiate cost-effective treatment plans.

In addition, they must have the ability to collaborate with other healthcare professionals, speak effectively with patients and families, and discuss the financial implications of care plans. All of these skills are essential for success in this role, as they contribute to improved patient outcomes, cost savings, and effective utilization of resources. When a utilization review case manager has mastered these abilities, they can help ensure that the best care is being provided to their patients in an efficient and cost-effective manner.

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Frequent Interview Questions

• What experience do you have working in utilization review?
• How would you prioritize competing demands for a patient’s care?
• What challenges have you encountered in performing utilization review?
• How do you ensure compliance with insurance regulations and standards?
• What strategies do you use to work effectively with physicians, healthcare providers, and patients?
• How do you stay up to date on changes in insurance regulations and standards?
• Describe a situation where you had to make a difficult decision regarding utilization review.
• How do you determine the best course of action when presented with conflicting information?
• What strategies do you use to successfully manage a high caseload?
• Describe a time when you successfully negotiated with a third party payer to approve treatment.

Common Tools in Industry

1. Microsoft Access. Database software for organizing and archiving information. Example: Storing patient records in a secure database.
2. Electronic Medical Records (EMR). Software for tracking patient information electronically. Example: Inputting and tracking patient information such as medications, diagnoses, and health history.
3. Utilization Review Software. Software that helps to review the appropriateness of services provided to patients. Example: Comparing patient data to accepted standards of care and determining if additional services are necessary.
4. Document Management Systems. Software for creating, storing, and organizing digital documents. Example: Creating utilization review reports and storing them securely in a digital filing system.
5. Data Analysis Software. Software for analyzing large amounts of data quickly and accurately. Example: Examining trends and patterns in utilization review data to identify areas of improvement.

Professional Organizations to Know

1. American Case Management Association (ACMA)
2. American Board of Quality Assurance and Utilization Review Physicians (ABQAURP)
3. The Utilization Review Accreditation Commission (URAC)
4. National Association of Managed Care Nurses (NAMCN)
5. American Society of Professionals in Patient Safety (ASPPS)
6. National Association of Healthcare Quality (NAHQ)
7. American Health Care Association (AHCA)
8. American College of Medical Quality (ACMQ)
9. American Society of Clinical Pathologists (ASCP)
10. American Medical Informatics Association (AMIA)

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Common Important Terms

1. Utilization Review. A process used by insurance companies and other health care providers to evaluate the appropriateness of medical care and services.
2. Quality Assurance. A process used to ensure that medical services provided meet accepted standards of care and are cost-effective.
3. Peer Review. An evaluation of medical care by qualified medical professionals to promote quality improvement, cost-effectiveness, and appropriateness of services.
4. Clinical Criteria. Standards used to determine the level of care needed in a particular situation.
5. Discharge Planning. A process used to ensure that an individual's needs are met upon discharge from a healthcare facility.
6. Primary Care Physician. A physician who provides general, first-contact health care services.
7. Medical Necessity. The necessity for a particular medical service based on accepted standards of care and cost-effectiveness.

Frequently Asked Questions

What is a Utilization Review Case Manager?

A Utilization Review Case Manager is a health care professional who is responsible for ensuring that medical services are provided in an effective and cost-efficient manner. They are responsible for assessing the appropriateness of medical care and making recommendations to adjust treatments and ensure quality care.

What qualifications do Utilization Review Case Managers need?

Utilization Review Case Managers typically need to be registered nurses with at least a bachelor’s degree in nursing or a related field. They must also be licensed to practice in their jurisdiction and have experience in medical case management.

What are the responsibilities of a Utilization Review Case Manager?

The primary responsibility of a Utilization Review Case Manager is to review medical records, evaluate care plans, and recommend changes or adjustments to ensure the best possible outcomes for patients. They also monitor patient progress, provide guidance to providers, and ensure compliance with regulations and standards.

What type of environment do Utilization Review Case Managers work in?

Utilization Review Case Managers typically work in a variety of environments including hospitals, long-term care facilities, managed care organizations, and insurance companies.

What skills are important for Utilization Review Case Managers?

Utilization Review Case Managers need to possess excellent communication and analytical skills, as well as knowledge of medical terminology, coding systems, and clinical guidelines. They must also be organized and detail-oriented, with strong problem-solving abilities.

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Web Resources

• Utilization Review Case Manager at Cedars-Sinai jobs.cedars-sinai.edu
• Utilization Review Case Mgr Per Diem 8HR at Cedars-Sinai jobs.cedars-sinai.edu
• Case Management - UC San Diego Division of Extended Studies extendedstudies.ucsd.edu