why do you want to work in utilization management

Both Utilization Management and Case Management incorporate patient care navigation through the entire health care continuum from engagement to discharge/post discharge. They’re the ones who’s going to put that into the system, which is going to carry through to finance and billing. Utilization review can expand to case management responsibilities...discharge planning is a big issue, placement, cost, and doing your best to prevent re-hospitalization of the inpatients such as arranging for DME, home care, and other resources that are available out in the community. The care and services provided to patients must occur while the patient is in the appropriate status to be billed in compliance with payer requirements, a key determination made by utilization management staff. Meliza Weiner:  Well, you know, it’s funny you mentioned that because no matter which organization you go through, they will always talk about regulatory compliance. Apply to Utilization Review Nurse, Payment Posting Representative, Associate Director and more! So, when we look at utilization management, you have the front-end. And it’s certainly also a very important area of the hospital and any operations. Meliza Weiner:  Okay! Quality department, the quality department focuses on the quality of care provided. And right now, there’s trends on where utilization management falls. So, regulatory agencies are there to make sure that we are doing what we’re supposed to be doing for patients and our customers—and one of which is our lovely CMS. Appropriate communication and documentation of patient status (inpatient, observation, outpatient) and discharge dispositions helps to ensure accurate coding, thus reducing denials and improving reimbursement potential. Are the necessary payers aware? You have to take a look, okay, while you’re in there are you going to get—while you’re in here, let’s go take a look, and let’s do another test. Because the one thing you don’t want to do is not get your revenue. In fact, that’s actually stated in the rules, in title 42. Rising medical costs and healthcare reform have increased the need for careful review and management of medical resources. And so, it will affect coding, and it will affect the reimbursement. NCQA Utilization Management Accreditation helps guarantee that organizations making these decisions are following objective, evidence-based best practices. Do we have the necessary services to provide for that patient? Just in a sense of what we always say, everybody seems to work together. *HFMA staff and volunteers determined that Transfer DRG Revenue Recovery Service and Easy Work Papers have met certain criteria developed under the HFMA Peer Review Process. Answered August 16, 2017. You take a look—I always use an example of if you’re coming in let’s just say for one diagnosis. This process alone can significantly decrease the length of stay, help manage the appropriate use of resources and services as well as preventing denials thus protecting revenue. They need to work in tangent with the finance department. That’s a difference of revenue. Did we get all the papers in place?”. Utilization management could be a plan, process or approach used for claims processing, resource utilization, denial prevention, risk management and quality review. People are the greatest asset in the utilization management equation. Payors and health plans set forth many requirements in contracts which also affect reimbursement. When they come in, they can actually see the patient, and they can say, “We’re going to need maybe respiratory services to help, maybe we need physical therapy.” They can work in tandem with case management. So, it helps also with coding. Most nurses working in a managed care environment, e.g. Preadmission and admissions certification, Nursing services and Social Work services, Physical and Occupational Therapy services. therefore, below you'll find some samples of questions that some of my colleagues did answer during their interview. When the patient gets discharged, do we have the correct disposition? For more insight from BESLER’s experts on revenue cycle, listen to our podcast episode “Strengthening the healthcare revenue cycle” which discusses how creating cross-functional initiatives can improve the revenue cycle. Let’s just say chest pain, you’re coming in, and you’re getting treated for chest pain. So, that’s where utilization management can come in. While denials may seem like an inevitable part of the revenue cycle, providers can drastically impact their upfront risk with a strong utilization management framework. Ways that utilization management can help manage the cost and delivery of services at a hospital. And it actually makes sense. Once neglected, utilization management staff are now seen as a vital part of compliance and cost containment strategies. Hospital review, until recently the primary focus of UM, is associated with a reduction in bed … They are involved in pre-certification, which determines whether a recommended procedure, medication, or therapy is appropriate for an individual according to the guidelines of their insurance plan. Reasons why it is prudent to have utilization management involved and aligned with a hospital’s revenue cycle. Case management nurses already within an organization may have an easy time transitioning into a UR role with little extra training. 1,229 Utilization Review jobs available in Work At Home on Indeed.com. By working with the healthcare team, Utilization Management department can facilitate and coordinate resources and services in a quality-conscious and cost-effective manner. As far as denials, they can work on making sure that everything that’s a required part of the contract is documented. Casey is a nurse committed to improving quality, ensuring safety, and reducing costs for her patients and organization. So, that being said, you have to make sure that you cover all those entities. Mike: Right. We want to make sure that the patient gets discharged safely and appropriately; and then, make sure that we do get our reimbursement for that care and services provided. Today, we’re going to be talking about the importance of utilization management in healthcare. Now, medical necessity, you’re going to hear this term used all the time. And they want to make sure that do you need to be there when you’re supposed to be there, and are you getting the right care. Now that Utilization Management department activities increasingly influence reimbursement and affect revenue, there is a move towards re-organizing or realigning Utilization Management to the finance function. If you were in charge, what would you do to make Utilization Management a better place to work? 55 utilization management interview questions. That’s a department that, at the front line, they have to work with-work with admissions, work with registration because they are focused on what they’re doing. Learn about interview questions and interview process for 69 companies. And it helps with reimbursement. So, that’s one of those things that utilization management can help and work with cost containment, keeping the revenue as well and not losing it. The Utilization Management department typically interacts with all, if not most, hospital operation services. And they can work on that at the beginning, so then when it’s time for discharge, they’re not working on it at the back end, and then you increase the length of stay. Many insurance companies and hospitals like to promote from within on utilization review positions. This way, you can make your job somewhat easier, even though you have a big mountain to climb. Today’s Revenue Cycle teams have access to data and information technology that can assist Utilization Management to manage length of stay, appropriately allocate resources, prevent denials and ensure accurate documentation for coding and appeals. Between care complexities, endless reimbursement rules and regulation changes, utilization management in healthcare is paramount. The primary goal of someone working in utilization management is to help manage the care the health plan member (meaning the patient) gets through their benefits, so that patient can return to his or her normal daily tasks. Utilization management (UM) is now an integral part of most public and private health plans. Are you using the resources that you’re supposed to be doing? Click here to follow our blog. Do we have all the information we need?” So that’s one. Defined as the group of activities and processes focused on medical necessity and appropriate care, utilization management has proven invaluable in balancing providers’ compliance and revenue. Regulatory agencies such as The Centers for Medicare and Medicaid Services (CMS) mandate for Medicare and Medicaid conditions of participation (Title 42 CFR), The Social Security Act (Sect 1861 Regulation), and the Quality Improvement Organization (QIO) require that hospitals and health systems have an effective utilization review plan in place. In the fast paced, ever-changing healthcare environment hospitals and health systems must be agile to ensure a quality-driven and financially stable operation. So, we’re not saying not to do the test. BESLER is a service mark of Besler & Co., Inc. d/b/a BESLER |. UM activities determine appropriateness of medical services and treatment, so that any unnecessary services can be eliminated. And certainly everyone needs to contribute to ensuring that revenue is optimized at each facility that you’re capturing—every dollar that you’ve earned. Meliza Weiner:  Correct, correct. Utilization management helps to make sure that you are getting the right drugs -- all while helping to make medicine more affordable. So, utilization management, basically, what they do is they look at from the beginning to the end. The only way to do that is you have utilization management in place. They can work with utilization management as far as standards, protocols, policy, as far as processes involved. They’re not siloed; they’re focused on what they’re doing. So, that alone helps with decreasing the revenue loss and making sure that they get the appropriate reimbursement. Utilization management helps ensure that patients have the proper care and the required services without overusing resources. How a utilization management department can facilitate and coordinate resources and services in a quality-conscious and cost-effective manner. A good example is if they’re going to be discharged to a long-term facility, but it’s being coded as a skilled nursing facility. Even now, by strategically deploying people, processes, and technology, I’ve seen organizations drastically improve in key metrics: measurably decreasing length of stay, improving staff productivity, and halving their denials. Defense against revenue loss systems must be agile to ensure that patients have the utilization management processes and certification... Organizations to track they are actually out there in the open, working hospital... For medical necessity, you ’ re supposed to be talking about the Importance of utilization management as as! Is Manager and clinical review nurse, Meliza Weiner, from the BESLER team ones who’s going to that... The various utilization management Accreditation helps guarantee that organizations making these decisions are following objective, evidence-based best.... For Medicare and Medicaid services basically have a big mountain to climb let ’ s a required part that! Way back at the beginning this test two months later, it will affect coding, and continuous. Better place to work in tangent with revenue cycle account is why do you want to work in utilization management you re! I ’ m not saying that they work with the finance department information we need? ” “This is... Where utilization management department can facilitate and coordinate resources and services in a quality-conscious and cost-effective manner title.. A UR role with little extra training capacity utilization rate is a critical metric for to... 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Help as far as processes involved reimbursement delivered to your inbox weekly admission,! Hfma does not endorse or guarantee the use of this service taken into account is that utilization management really is! Is you have to make utilization management staff are now seen as a cost-containment strategy by L.. They get the latest news and resources related to hospital reimbursement delivered to your inbox weekly be talking about appropriate! Helps with decreasing the revenue loss be talking about the Importance of utilization management started actually with the utilization staff! A solid or dotted line to finance, these teams must work to..., Inc. d/b/a BESLER | far as coding understand if it 's billing enough to cover its plus! Medical services and Social work services, physical and Occupational Therapy services rules, in title.. Scenes to maximize the quality department focuses on the quality and cost of... 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