Utilization management question

I would say the interqual had a short learning curve of less than a month because it was basically check a box and get a green or red light. Milliman took a good 6 months to really be able to find stuff fast and write the rational.

We are not talking STUFF here.

We are talking about applying evidence based practice.. as it applies to the level of care the patient requires.

Interqual, Milliman.. whatever..utilization review requires nursing judgement .

That's why they pay me the big bucks.

Big Bucks?

@been there....

Perhaps "stuff" was not a word choice to your liking? How about I phrase it as finding the appropriate criteria based on the clinical documentation supplied by the physician or facility? I do complex CM and I do my own UR on the patients I have in LCM, therefore I work in two separate areas in the same system. What nursing judgement has to do with the UR process is understanding the complexity of the disease to be able to know the appropriate criteria to employ and interpret that into a medically necessity review. BUT the bottom line is if the 'stuff' does not meet the cookie cutter hole of milliman or interqual etc. I can't say per my nursing judgement I will cert it. Nope, I must say I am sending it for a physician review.

big bucks, are in the eye of the beholder when they check their pay stub :-)