Medical Management Guide, 2009, Version 3.0 - Tricare

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Page 52Utilization Management Version 3.0Medical Management GuideUTILIZATION MANAGEMENT PROGRAMACCREDITATIONAs part of the TRICARE contract requirement,network facilities are required to obtain andmaintain URAC accreditation for their UMprograms. For more information, go to:http://www.urac.org..THE UTILIZATION MANAGEMENTPROFESSIONALQualificationsThe job description of the employee workingin the UM department of an MTF will varydepending on the size of the organizationand its internal resources. Titles include UtilizationManager, Nurse Consultant, and Clinical NurseSpecialist. The UM professional should possesssufficient clinical knowledge and breadth ofexperience in patient care to identify the clinicalrationale for procedures or tests. He/she shouldbe able to gather necessary information anddetermine the medical necessity of services andappropriateness of certain levels of care.Good communication skills are imperative. In theirgoal of providing UM information to clinicians andhospital leadership, UM professionals may interactclosely with the following roles and/or personnel:1. Population Health Nurse Consultant2. Health Care Integrator (HCI)3. Group Practice Manager (GPM)4. Coders5. Patient Administration staff6. Medical Records staff7. MCSC staff8. Provider teams9. MTF MM and Managed Care divisions10. Resource Management staffThe following are specific education and trainingrequirements for the UM position:• Licensed Registered Nurse (RN) – i.e., graduateof an accredited nursing program, Bachelor ofScience in Nursing (BSN) preferred; or possessinga bachelor’s (or higher) degree in a healthcarerelatedfield from an accredited educationalinstitution (position typically occupied by an RNwith a BSN).• A minimum of three years of progressivelyincreasing managed care responsibilities, with afocus in UM and/or a minimum of three years ofbroad-based clinical nursing experience (UM/URfocus preferred).• Current Basic Life Support (BLS) certification.• Knowledge and experience (or comprehensionduring training) of software and databasescurrently employed at the MTF (e.g., CompositeHealth Care System [CHCS], Armed ForcesHealth Longitudinal Technological Application[AHLTA] — see Section V, MedicalManagement Tools).• Familiarity with customer-focused and processimprovement principles.• Full-time employment for the past twelvemonths in a healthcare-related field.• Valid unrestricted clinical license to practice fromthe state where the MTF is located or licensedthrough the Nurse Licensure Compact (NLC)if the UM professional is not Active Duty. Formore information and a list of states, visit thejoint website of the Nurse Licensure Compact
Medical Management GuideVersion 3.0Utilization ManagementPage 53Administrators (NLCA) and the National Councilof State Boards of Nursing (NCSBN): http://www.ncsbn.org.Desirable qualifications are as follows:• Certification by a UM-specific program (mostdesirable) or a professional organizationrecognized by an accrediting body for UM, suchas:o American Nurses Association (ANA):http://www.ana.org/ancco American Nurses CredentialingCenter (ANCC):http://www.nursingworld.org/ancc/o National Association of Healthcare Quality(NAHQ) Certified Professional in HealthcareQuality (CPHQ): http://www.nahq.orgo McKesson: http://www.mckesson.com/o McKesson Certified Professional inUtilization Review (CPUR) TMo McKesson Certified Professional inUtilization Management (CPUM) TMo McKesson Certified Professional inHealthcare Management (CPHM) TM• Experience with Microsoft Office software.• Master’s degree.• Six years of broad-based clinical experience.Staffing to Support UtilizationManagementand a link to higher-level data analysis and URfunctions. Communication and collaborationbetween UM and the RMC — as well as with theother components of CM and DM — needs to beseamless.SUMMARYAs healthcare organizations haveimplemented MM, a shift has occurred inthe UM role from its historical focus oncost containment to a more proactive approachof continuous quality improvement and evidencebasedpractice. Organizations that use UM solelyto determine services and cost (i.e., that implementbenefit management) tend to diminish their primaryfocus on the patient, which can cause interferenceor delays in coordinating patient care. Nonetheless,UR and preauthorization remain an important partof UM, wherein LOS and appropriateness of care arereviewed, so that problems can be identified earlyenough for intervention.A successful, cost-efficient, and effective UMprogram depends on skilled, well-trained staffinformed about current approaches and trends. Asthe field of UM continues to evolve, every UM staffmember should view him/herself as a stakeholderin developing better healthcare delivery modelsthroughout the MHS.Personnel functioning separately under the RMCneed to establish a direct working relationshipwith their UM department. While RMC staff mightperform many of the tasks related to routine, dayto-dayreferral processing, there should be a UMprofessional (e.g., a UM nurse) providing oversight
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