Utilization Management

Involves the review of medical records, admissions, continued stay and outpatient services for appropriateness, medical necessity, and quality. Often works as case management team member, in concert with physicians, nurses, social work, discharge planners, and other allied health professionals. Reviews care and treatment received. Communicates with third party payers in order to obtain authorization for care and facilitates clinical denial and appeal process as necessary. Acts as a resource to related parties by providing training and educational sessions.