By the end of this course, participants will be able to:
Articulate comprehensive UR practices tailored to Medicare, Medicaid, VA, and commercial insurance.
Describe specific utilization review requirements for specialty areas such as NICU, behavioral health, and elective surgical services.
Identify the key phases of utilization review and outline strategies to strengthen collaboration with Physician Advisors.
Evaluate denial types & assess how utilization review processes influence clinical, operational, and financial performance.
Meet the Speakers
TIFFANY FERGUSON, LMSW, CMAC, ACM
CEO of Phoenix Medical Management, Inc.
Tiffany serves as an adjunct professor at Northern Arizona University, Department of Social Work, and on the American College of Physician Advisors (ACPA) Observation Committee. Tiffany is co-author of The Hospital Guide to Contemporary Case Management through HcPro. She is a contributor for RACmonitor and Case Management Monthly; she also serves on the editorial board for CMSAToday and Care Management. She is a weekly correspondent on SDoH for the news podcast Talk Ten Tuesday. After practicing as a hospital social worker, she went on to serve as Director of Case Management and quickly assumed responsibilities in system level leadership roles in Health & Care Management, which includes CM, UR, CDI, HIM, and coding. She has held C-level responsibility for a large employed medical group which included value-based arrangements and outpatient care management. Tiffany is a graduate of Northern Arizona University and received her MSW at UCLA. She is a licensed social worker, ACM, and CMAC certified.
SARA WILLIAMS, MSN, RN, ACM-RN
Vice President of Clinical Strategy
Sara Williams has over 35 years of healthcare and, since 2009, has been dedicated to the advancement of case management in the acute inpatient and ambulatory care management settings. She was instrumental in the development of an integrated case management/population health model that addressed care across the continuum for a major health system and served as a System Director of Case Management for a large health system, where she led the implementation of a standardized care management model for all acute care facilities within the system. Sara has extensive experience in leadership, case management, and utilization review. She recently implemented a system-wide program to incorporate pre-claim denial management strategies into the utilization review process. This process included collaboration with Revenue Cycle, Contracting, and Physician Advisor partners, to ensure appropriate reimbursement for services provided to patients. Sara holds a Master’s degree in Nursing with a concentration in Leadership & Management and is certified in Case Management with the American Case Management Association.
About the Course
This is a comprehensive advanced course of utilization review and how to excel in your role as an elevated UR Specialist. The target audience is any RN in the field of UR that has taken the Essentials of UR Course. This course will be a live, virtual cohort class 1 hour a week for 4 weeks.
Who Is This For:
Case Managers, Utilization Review Specialists, Directors and Managers who provide oversight to Case Management and Utilization Review programs. This program requires experience performing the daily functions in the utilization review nurse role either in frontline or leadership capacity.
Course Outline and Agenda:
Week 1: One hour class discussing all things Medicare, starting with the evolution of Medicare Advantage, CMS updates and how they affect the UR process, and Medicare as primary/secondary payer. Week 2: One hour class identifying the specific UR requirements for specialty areas like maternity, NICU, behavioral health, and surgeries. Week 3: One hour class understanding effective utilization review processes in all areas of the organization and classifications for bedded outpatients. Week 4: One hour outlining effective denial management, documentation of avoidable delays, and a review of Key Performance Indicators (KPIs) that demonstrate the effectiveness of a UM program.
Registration Info:
The cost for this virtual workshop course is $250 which includes a certificate. Register online at https://www.phoenixmed.net/education. Please contact [email protected] if you have any questions, concerns or need special accommodations. Registration closes 3 days before class begins. Cancellations must be received 2 weeks prior to the end of the course completion and a refund will be issued for the course.
Refund/Cancellation Policy in the event of Non-Attendance:
A full refund will be issued if requested up to 2 weeks before class starts, and a payment credit can be used to reschedule the class for a future date. CE contact hours will only be credited for full course attendance and completion. Phoenix Medical Management has been approved by the California Board of Registered Nursing, Provider #17829, for 4.0 Contact Hours. 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 4.0 contact hours. Activity code: S00065806; Approval Number: 250004102. To claim these CEs, log in to your CE Center account at www.ccmcertification.org.