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Program Description:
This is a fully asynchronous online course delivered through video modules, interactive case examples, and downloadable tools. Learners may complete the course at their own pace, allowing flexibility for working professionals in hospital and emergency department settings. This course provides a practical, practice-focused overview of utilization review (UR) within hospital and emergency department environments. Participants examine the purpose and function of utilization review, medical necessity standards, and level-of-care determinations, including observation, inpatient, and outpatient-in-a-bed classifications. The course also addresses regulatory and compliance requirements, documentation standards, and common challenges encountered in real-time utilization review workflows. Upon completion of this course, learners will be able to apply utilization review principles to real-world clinical scenarios, accurately assess medical necessity and level of care, and navigate regulatory and documentation requirements with confidence. Learners will strengthen interdisciplinary communication skills, collaborate effectively with providers and case management teams, and support compliant, patient-centered care decisions across acute care settings.
Learning Objectives
1. Identify the purpose and core functions of utilization review within hospital and emergency department settings. 2. Apply medical necessity principles and level-of-care criteria to utilization review decision-making. 3. Differentiate observation, inpatient, and outpatient-in-a-bed statuses and their implications for patient care and reimbursement. 4. Recognize regulatory, compliance, and documentation requirements relevant to utilization review practice, including CMS Conditions of Participation. 5. Implement effective communication strategies with providers, case management, and interdisciplinary teams to support compliant and timely utilization decisions.
Who Should Attend
If you work with patients in hospital or healthcare settings, this course is for you. Especially helpful for: Medical and hospital social workers Case managers Nurses involved in discharge planning Behavioral health clinicians Professionals seeking practical tools for trauma-informed, ethical care planning
Meet Your Course Author, Tiffany Ferguson
Tiffany Ferguson, LMSW, CMAC, ACM, is the CEO of Phoenix Medical Management, Inc., the leading case management firm. After practicing as a hospital social worker, she was tapped to serve as Director of Community Case Management and quickly assumed leadership responsibility as System Director of Health and Care Management and later top Administrator for the employed medical group. Ms. Ferguson is CMAC, and ACM certified, and serves on the Observation sub-committee for ACPA. She is a weekly contributor on RACmonitor, Case Management Monthly, and commentator for Finally Friday. Tiffany is a graduate of Northern Arizona University and received her MSW at UCLA.
Meet Your Course Author, Kalie Wolfinger
Kalie Wolfinger, LCSW, is the Manager of Clinical Services for Phoenix Medical Management. Kalie brings nearly 13 years of clinical social work expertise across primary care and hospital settings. Her diverse experience includes roles in emergency department clinical social work, integrated behavioral health within primary care, and case management in hospital inpatient psychiatric units and general hospital settings. In addition to her healthcare contributions, Kalie is an educator in higher education, teaching both Bachelor of Social Work and Master of Social Work programs. She also maintains a private practice, specializing in supporting first responders, crisis intervention, trauma, and dissociation and is certified through the ACMA. She holds an MBA and a Master of Science in Nursing (MSN) with a focus on Nursing Leadership.
Course Agenda and Outline:
This self-paced course includes focused instruction through short video lectures, downloadable handouts, and clinical practice tools. Each module includes interactive knowledge checks and real-life case applications. 1. Introduction to Utilization Review Overview of utilization review in hospital settings Purpose and goals of utilization review Relationship between utilization review, case management, and care coordination 2. Medical Necessity and Level-of-Care Determination Definition of medical necessity Use of clinical criteria and evidence-based guidelines Role of utilization review in level-of-care decision-making 3. Observation, Inpatient, and Outpatient-in-a-Bed Status Distinctions between observation, inpatient, and outpatient-in-a-bed Clinical, operational, and financial implications of each status Impact on patient experience, documentation, and reimbursement 4. Utilization Review in the Emergency Department Time-sensitive utilization review decision-making in the ED Challenges related to rapid patient turnover and limited information High utilizers and frequent emergency department presentations 5. Documentation, Compliance, and Regulatory Considerations Documentation standards for utilization review activities CMS Conditions of Participation and compliance requirements Importance of accurate, timely, and defensible documentation 6. Interdisciplinary Communication and Collaboration Communicating utilization review decisions with providers Collaboration with case management, nursing, and physician teams Managing disagreements and clarifying level-of-care determinations 7. Common Challenges and Best Practices in Utilization Review Barriers to effective and timely utilization review Balancing regulatory compliance with patient-centered care Strategies to support efficient, compliant workflows 8. Course Summary and Knowledge Review Key utilization review concepts and practice takeaways Application to hospital-based utilization review practice Course Completion Requirements: The course is completed after viewing the modules and completing the reading. Each module includes practical tools, real-world examples, and a brief knowledge check to reinforce learning. Posttest requirements-Participants must achieve a passing score of at least 80% to receive continuing education credit. If a participant does not pass on the first attempt, they will be provided with one opportunity to retake the test after reviewing the course materials. If the second attempt is unsuccessful, the participant will be encouraged to revisit the course content and may request additional support or clarification before attempting the test again. The posttest must be completed, along with the course evaluation before a certificate is issued. The course certificate will be delivered via email within one week of evaluation completion. Phoenix Medical Management has been approved by the California Board of Registered Nursing, Provider #17829, for 1.0 Contact Hour. This program has been pre-approved by The Commission for Case Manager Certification to provide continuing education credit to CCM ® board certified case managers. The course is approved for 1.0 contact hour. Activity code: I00066153; Approval Number: 260000206. To claim these CEs, log into your CE Center account at www.ccmcertification.org.
Registration Info
Please contact Vanessa Blutrich at [email protected] if you have any questions, concerns, or need special accommodations. System Requirements: Internet access and a modern web browser.
$65.00