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Utilization Management

The principal objective of utilization management is the reduction of practice variations by establishing parameters for cost-effective use of health care resources. There are four main techniques or tools used in utilization management: demand management, utilization review, case management, and disease management. Utilization management helps MCOs control costs and improve quality.

Refer to the readings of this week and the Internet on the above information, answer the following questions:

• What are the challenges faced by MCOs regarding practice variations? What do you think can be done to meet these challenges?
• Differentiate between the three main processes of institutional utilization management.
• Determine the main purposes of each process of institutional utilization management? Which process do you think is the most important, and why?
• Research the role of the utilization management nurse.
• Explain the functions of the utilization management nurse, and compare and contrast the information from that organization.
• Explain your understanding of disease management and case management. What in your opinion are one major similarity and one major difference between the two types of management?

Now, access information on disease and case management by searching the Internet by using the following keywords:

• Care Continuum Alliance
• Commission of Case Manager Certification

Based on your research, answer the following questions:

• What is the purpose or mission of these professional organizations?
• What standards do these organizations set for certification or membership?
• How do these organizations define disease or case management and do they differ from the text definitions?