Utilization Review vs Case Management

where i work, case management is split into two divisions: discharge planning and utilization review. discharge planners work on each unit in the hospital and have a caseload of anywhere from 30-40 patients. they do case management evaluations on each patient and make all discharge arrangements, i.e., transfers to skilled nursing, alf's, arrange for home o2, walkers, canes, etc. on the other hand, the utilization review nurses review the medical record to determine correct status (inpatient or observation) of each new patient. they also do concurrent reviews for patients already in the hospital to determine when they no longer meet criteria to stay in the hospital.

i hope this helps you some......

.. building on QTBabynurse.. UR is a process of determining medical necessity using evidence based criteria such as InterQual or Milliman (or just solid medical rationalization). In patient UR nurses are responsible for communicating their reviews to insurance UR nurses for reimbursement authorization. Some hospitals combine the 2 jobs.

Many UR nurses become case managers or are already case managers. As already pointed out, UR staff review cases and contact payers for reimbursement of procedures and services. UR is mostly a function of nursing. Sometimes you may find workers from health information management performing UR duties. The UR staff may be divided into retrospective review, concurrent review, and discharge planning. As far as case management is concerned, case managers can be social workers, nurses or other disciplines who help patients manage health and medical resources. They may work directly with providers to see that the patient or family have what they need in an efficient, economical, and effective manner. The case managers for most payers have overlapping duties as UR and discharge planners as well as specific or general case management. Hope this helps.

I am a Manager at a Medicare Advantage plan and we have transitioned all of our Field Nursing Staff from UR Nurses to Case Managers as we wanted them to view the members Holistically and not just view them as IQ, MR, or CMS criteria.

One of the jobs done by UR, at my hospital, is looking at the medical necessity including obs vs inpt, appropriateness of services and procedures ordered, length of stay as indicated by insurance criteria, and discharge planning and dispostion. It is done concurrently based on Interquel and CMS guidelines. UR also sends all clinicals and obtains authorization from insurance companies. Lots of responsibility . This has been done by one person; a social worker who is often referred to as the case manager (not certified). This is now changing at my hospital. A case management team has been formed. It includes 3 RN's, 1 social worker and 1 coder. It is over seen by the CCO and HIM manager. The RN's coordinate the care to improve quality and continuity at the same time insuring fiscal responsibility for the patient and hospital. This includes:

• Assessing all admissions for medical necessity
  
• Patient advocate
  
• Clinical care coordination
  
• Coordinate the services associated with discharge (whether home or another facility)
  
• Provide patient education
  
• Provide post-care follow-up
  
• Coordinate services with other health care providers
  

The social worker will primarily do UR:

• Verify coverage & benefits with the health insurers to ensure the provider is appropriately paid
  

Our social worker also handles all psychosocial issues that involves patients and families.

This is how we set up case management and UR at our facility. These are the primary responsibilites for each discipline but we work as a team and have overlapping as needed. Hope this is helpful.

Do you also do medication review?

When I worked for an insurance company they made a big distinction between case management and UR/DCP. They educated their case managers more thoroughly. We were primarily involved with disease management and counseling patients on staying healthy. We made referrals for health care information and coordinated care. We assessed for problems and assisted the patients in problem solving.

In the hospital, case management is more the UR/DCP piece; performing utilization reviews, assessing for severity of illness and intensity of service. We also do discharge planning. The hospital social workers do what we did in the way of referrals and counseling.

I prefer case management, but hospitals pay better and have better benefits.