Effective Care Management involves many people with differing roles and responsibilities, collaborating for the benefit and wellbeing of patients/members. Care Management itself is a wide umbrella, which Utilization Management (UM) and Case Management (CM) are both under. Depending on the structure of an organization, UM may be a stand-alone service in partnership with CM, or a CM department may be responsible for UM tasks.
Utilization Management: The UM Nurse
A UM nurse is responsible for ensuring that the right care is delivered at the right time, without over/under-utilization of resources. Tasks of a UM nurse include the intake of a requested service, evaluating if the service is a covered benefit within a patient’s/member’s insurance plan, determining if it is medically necessary (per a specified guideline), and securing the final decision (i.e., approval/denial of the requested service). A UM nurse may communicate the outcome to a Case Manager, refer a patient/member to a Case Manager or Care Management Program, and/or further assist the Case Manager with discharge planning and continued length of stay requests.
Check out 3 best practices of a successful utilization management program.
Case Management: The Case Manager
A Case Manager evaluates a patient/member and determines their needs (e.g., services, procedures, placement) and what is required to get everything in place for the patient, which usually includes a UM-component. Goals of a Case Manager include assisting the patient/member in reaching optimum wellness, reducing occurrence of readmission, and coordinating care with the Interdisciplinary Care Team. Again, any UM tasks may be handed off to a separate UM department, or the Case Manager could perform those tasks themselves, depending on the organization’s structure.
In all, the Case Manager and UM nurse have differing roles/responsibilities but should always be collaborating to drive positive healthcare outcomes.
