Utilization Management: Clinical Review and Care Coordination

Course Purpose

This course teaches utilization management through eight connected topics. Assessments are optional, non-gating learning activities; all cases are illustrative rather than reports of actual patients.

Continuing Education Credit Designation

This educational activity is credited for 4 contact hours at completion of the activity.

Overview

This course teaches utilization management through eight connected topics. Assessments are optional, non-gating learning activities; all cases are illustrative rather than reports of actual patients.

Objectives

Upon completion of this independent study, the learner will be able to:

1. Explain how utilization management connects cost awareness, safe care, coordination and patient experience.
2. Differentiate prospective, concurrent and retrospective review by timing and purpose.
3. Separate nursing evidence review from authorized medical necessity, benefit and level-of-care determinations.
4. Prepare a physician-advisor referral identifying documented findings, uncertainty and the decision requiring review.
5. Apply screening, assessment, planning, implementation, monitoring and evaluation within a variable case management process.
6. Develop patient-centered goals linking healthcare needs with psychosocial supports and measurable outcomes.
7. Assess functional ability, understanding, caregiver support and financial access during transition planning.
8. Coordinate individualized handoffs and follow-up across hospital, home, rehabilitation and community settings.
9. Interpret readmission information without treating association as proof of preventability or program effectiveness.
10. Distinguish benefit denials, medical necessity disagreements and applicable physician or beneficiary review pathways.
11. Construct truthful clinical summaries without altering or misrepresenting documentation to obtain authorization.
12. Apply source-described HIPAA safeguards while escalating disclosure and information-handling uncertainty.
13. Recognize emergency screening, stabilization and transfer concerns requiring immediate clinical and organizational escalation.
14. Support informed, voluntary participation using understandable communication and assessment of comprehension.
15. Select improvement methods and primary and secondary measures that balance efficiency with safety.
16. Evaluate telehealth, public-program navigation and equity barriers without issuing nursing coverage guarantees.

Who this course is for:

Advanced Practice Registered Nurses, registered nurses, licensed practical or vocational nurses, and other healthcare providers in any setting who want continuing education on Utilization Management: Clinical Review and Care Coordination.

Course outline

12 sections · finish in any order across devices

1. 1

   Course overview and learning objectives

2. 2

   Introduction

3. 3

   The Utilization Management Nurse: Advocacy, Review, and Decision Boundaries

4. 4

   The Review Cycle: Timing, Criteria, Physician Advisors, and Honest Abstraction

5. 5

   Case Management from Screening to Evaluation and Closure

6. 6

   Discharge and Transitions: Readiness, Capacity, Follow-up, and Safe Timing

7. 7

   Documentation and Communication: Representing the Clinical Picture Truthfully

8. 8

   Denials, Appeals, Peer Review, and Safety Escalation

9. 9

   Privacy, Consent, and Emergency Access in Review and Coordination

10. 10

    Quality Improvement, Telehealth, Coverage Context, and Equity

11. 11

    Nursing Considerations

12. 12

    Conclusion

This Course Satisfies

Requirement summaries come from our state requirement records. All Users of Fast CE For Less’s website and content are responsible for knowing their state’s license and renewal requirements.

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