Introduction to Utilization Review

This is a hybrid asynchronous course combines recorded and written material. 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) in hospital setting. Participants will examine the purpose of utilization review, medical necessity standards, and level-of-care determinations, including observation, inpatient, and outpatient-in-a-bed classifications. The course also introduces payer-based considerations, including how reimbursement models, coordination of benefits, and Medicare Advantage plans influence utilization review workflows, documentation expectations, and decision-making. Emphasis is placed on regulatory compliance, interdisciplinary communication, and applying utilization review principles in real-time clinical practice. 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.

1. Identify the purpose and core functions of utilization review within hospital and emergency department settings. 2. Apply medical necessity criteria and level-of-care guidelines to utilization review decision-making. 3. Differentiate observation, inpatient, and outpatient-in-a-bed statuses and their impact on care delivery and reimbursement. 4. Recognize regulatory, compliance, and documentation requirements, including CMS Conditions of Participation. 5. Explain how payer type and reimbursement models influence utilization review workflows and decision-making. 6. Apply payer-focused thinking to support effective communication, documentation, and continued stay review processes.

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. 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.

Module 1: Understanding the Role of UR Module 2: The Utilization Review Team Module 3: The Three Phases of Utilization Review Module 4: Core Responsibilities of the UR RN Module 5: UR in the Patient–Provider–Payer Triad Module 6: Medicare Foundations & the Origins of Utilization Review Module 7: Conditions of Participation (CoP) & UR Committee Requirements Module 8: Medical Necessity Standards & Documentation Expectations Module 9: UR Process, Reactive vs Proactive Review, and Key Review Drivers Module 10: Inpatient Status & the Two-Midnight Rule Module 11: Observation Services & Level-of-Care Decision Making Module 12: Conversions — Observation to Inpatient Module 13: Conversions — Inpatient to Observation Module 14: Why Payment Type Matters in Utilization Review Module 15: Commercial Payer Payment Models and UR Implications Module 16: Primary vs Secondary Payers Module 17: Medicare Advantage as a Commercial Payer Module 18: UR Practice Integration — Thinking Like a Payer Module 19: Key Teaching Takeaways and Clinical Application