Utilization review involves a combination of reviewing medical records, as well as gathering information from physicians, patients, and consultants. After the information is collected, it is compared to national criteria and guidelines established for medical necessity to support the care requested. If the clinical data does not meet medical necessity criteria, the case is referred to physician advisors. With the employment of utilization review nurses, unnecessary inpatient stays have been reduced, healthcare providers have shifted care from mainly inpatient to outpatient care, and patients who may require discharge planning or case management have been identified earlier. The role of a utilization review nurse is fast-paced, and you must rely heavily on your previous clinical experience to make appropriate decisions and to apply gathered information to national guidelines and criteria.
Case management is a term frequently used to describe an approach for managing complex medical care.
This usually involves a multidisciplinary process that requires the coordination of many players in the healthcare delivery system, including patients, family members, and vendors. Case managers are used in a variety of settings. Hospitals employ them to manage the use of inpatient resources, to assist with discharge planning, and to implement clinical pathways. Community-based case managers deal with the Medicaid and Medicare populations, focusing mainly on the social and economic factors that interfere with their ability to access or comply with healthcare. These patients may require special interventions to avoid or delay hospitalization or institutionalization.