1. What is Utilization Review? | Nursing away from the Bedside….
  2. Utilization Management Explained
  3. Utilization Review Nurse Interview Questions and Answers | Clinical Review Nurse
  4. Is Utilization Review difficult to learn?
  5. What Is Utilization Review ????
  6. Non-bedside nursing: Utilization Review Registered Nurse
  7. Improving Quality of Care through Utilization Management

What is Utilization Review? | Nursing away from the Bedside….

hey Claires welcome to my channel Court,that is that Claire if you are a new,viewer hey there hey welcome to my,channel if you enjoyed this video please,dont forget to like us a like and,subscribe if you are oldie but a goodie,a returning viewer hey gray hey boy hey,whats good you know if I have on these,blue skirts that is a nurse related,video so today were going to be talking,about utilization review and I talked,about this before in a previous video,called why I left Nursing so you need to,go ahead hit pause if you have not,watched that video if you have not watch,that video check my description box,theyll be a link gonna watch that and,then come on back and it will continue,to that group and if you have seen it,already go ahead and keep on watching we,talked about utilization review in that,video and I just got a lot of questions,concerns and just I felt like it would,be good for me to provide my wealth of,knowledge if you can call it my my world,wealth of knowledge in regards to,utilization review because I know when I,search going into the to this specialty,it wasnt a lot of information so um,yeah if youre interested honey if you,thinking about leaving the bedside I,want to know your options youre just,interested in a specialty you heard,about it didnt really know what that,means or if you just want to be playing,on those hear me and get the nurse team,go ahead and stay tuned get hit like,subscribe okay so there are two sides to,utilization review theres the payer,side which is the insurance and theres,the provider side which is the hospital,and I can only provide you information,or my perspective from the hospital side,because Ive only worked in the hospital,setting as the utilization review,nursery nurse so what is utilization of,you,well youll and ensure view is a subset,of case management and basically what we,do is we review charts for the,appropriate appropriate utilization of,hospital services and this basically,boils down to levels of care inpatient,observation I know if youre doing your,chart checks and youre checking on your,orders like we always talked about you,will see a status order observation and,impatient these are levels of care these,levels of care are important to the hot,because it determines the amount of,money or determines yeah the amount of,funding that comes back in reimbursement,from the payer this is important from,the tech side because it determines how,much money that they have to give to the,hospital so levels of care are very,important especially if your patient,does not have a level of care or the,patient is in then not an appropriate,level care this can result in a denial,of payment or if your result in a lack,of payment or could result in a full,immerse me so this is important because,it is the money of the hospital so,utilization review its like this whole,facet that is behind the scenes its,kind of like having a watch you know,child way back in the day when people,used to buy the watches off the Canal,Street honey then things went last past,like two weeks two months if youre,doing good because the insides wasnt if,I wasnt wasnt good well the same thing,is the jewels honey lets be clear,because I know about watches and stuff,but the inside of the watch isnt good,so thats the same thing with,utilization review we are the background,of the hospital but if we are not,working efficiently and proficiently,then the hospital does not receive the,money that it needs to operate and make,sure that it is providing efficient safe,care because that goes the money goes,back into jobs and quit me and supplies,yada yada yada so um how do we determine,appropriateness appropriate levels of,care well there are two national,regarded guidelines and that is melamine,or it can be called mcg and intercom um,these are nationally renowned like,nationally known and we all kind of use,them as guidelines I say guidelines,because its not definitive sometimes,you have patients that dont meet the,subsets that are provided and these,patients are reviewed you know from a,medical necessity perspective now,depending on your facility medical,necessity can be decided by a physician,if you have a physician advisor or it,can be decided by the nurse using her,clinical judgment this is why a lot of,hospitals have,having a push to hire registered nurses,in this role because second to,physicians we have the highest level of,clinical judgment so to speak no tea no,shade okay so um I know some of you,asked about training well the only way I,know that you can get training,especially with these systems is through,on-the-job training thats how I got,training once I was on the job then I,got more in-depth training from the,actual providers Milliman and Inter qual,and also Ive got questions about,experience so that goes back to the,clinical judgment part thats why they,need nurses for this they need nurses,for utilization review because we use,our clinical judgement when the systems,the medical necessity cannot be defined,through the system the guidelines so if,you dont have much clinical experience,to go on Im not quite sure how much of,a service will you be our good service,or how much of a benefit you will be in,this role but that does not mean that,you cannot do utilization review I just,think it depends on the employer okay a,lot of times utilization review gets,confused with CBI clinical documentation,improvements and um nursing informatics,I look at my little nut shell sorry um,nursing informatics so let me just,explain the little bit that I do know,about these specialties and if you are,CDI nurse or you are nursing informatics,nurse thats actually in practice go,ahead and drop some comments give me,some information because actually I,would like to know more about those,specialties myself but from what I do,know clinical documentation improvement,so utilization review nurses we ensure,that appropriateness for levels of care,so the pace so that we can get the,hospital can get reimbursement clinical,documentation improvement they come in,and they make sure the physicians,documentation allowed aligns with the,billing and coding so that way when its,time to actually submit the information,on the back end to these payers,insurances,there are the documentation lines up in,the coding lines up so thats just,another technical side of things and,like I said thats all I kind of know,about that Im not an expert in that,area however Ive also heard about,nursing informatics and from what I,understand its using nursing to on,integrating technology and in biomedical,equipment to ensure that we are giving,safe patient care along with the,efficiency of nurses charting so they,use a lot of nursing informatics to help,build these systems like your epics and,youre Citrix is the Citrix excuse me,epic and Cerner to ensure and I know,both the system so where my head today,um epic and Cerner to ensure that they,on these EMRs are efficient for nurses,and nurse interaction so thats where,kind of nurse informatics comes into,play okay so more information about,utilization review is that generally,speaking this role is salary okay so,many of you are one of those nurses who,like to get to the game and get your,little twelve twelve hour shifts six,days a week,type thing you like your overtime this,might not be the length for you because,generally speaking they dont really,give over time you may get a bonus shift,or you may get time and a half on your,holidays but as far as I record racking,up the extra days and extra pay this,might not be your ministry sis um and,also shift hours so I work 14-hour,shifts some of my colleagues work five,eight and I even know some utilization,review nurses who do three twelves but,theyre generally in the IDI setting,interactions so if you are a nurse who,absolutely loves patient care and thats,what you want to do you dont want you,know you love your patients as we all do,but you just want to be hands-on all the,time utilization review may not be th

Utilization Management Explained

hello this is Dr Eric Bricker and thank,you for watching a healthcare Z todays,topic is utilization management,oftentimes abbreviated,um if you work in healthcare and health,insurance then you have to know what,utilization management is its,essentially a fundamental in how the,money Works in healthcare so what is,utilization management it is what is,called managing bed days at a hospital,what in the world does that mean so,believe it or not a hospital actually,has to go to the commercial insurance,payer for the individual BlueCross,United Signet Aetna Medicare Advantage,plan what have you and say hey so and so,is here and they have to get approval,for payment for a certain number of days,at the hospital the insurance company,just doesnt just say okay the persons,in the hospital will just pay for it,they say okay so and so is in the,hospital well pay for it for a day or,two days or five days so its based upon,clinical criteria so literally there are,utilization management sometimes theyre,called case management nurses at the,hospital that literally phone call and,give report they like pull the chart you,know on the computer they like literally,pull the paper chart and they read the,doctors notes and they tell the,insurance company whats going on with,the patient and they say okay the,persons not got pneumonia and the,insurance company says okay well well,approve you for three days or theyve,got a cellulitis which is a skin,infection well approve you for two days,or you a scoliosis surgery which is more,significant well approve you for five,days now lets say the person has to,stay for more than three days for your,pneumonia I mean nobody can predict the,future the insurance company cant,predict the future the doctor cant,predict the future I mean if I can only,tell you how many times I admitted a,patient with pneumonia and then all of a,sudden their stay took a turn for the,worse like sometimes that happens their,heart might go into atrial fibrillation,um with rapid ventricular response which,then causes pulmonary edema which,worsenses their oxygenation status and,all of that could happen on Hospital day,three when were about to send them home,oh youre looking great Mr or Mrs Smith,Oh no youre an afib with rvr and youve,got new pulmonary edema guess what,theres no way youre going to be able,to be discharged at home so I write that,in my note I put in the orders for you,know deltaism drip or whatever and then,the nurse from the hospital has to call,then the insurance company again say oh,you know so and so Mr so-and-so Mrs,so-and-so theyre not doing so good yada,yada yada and then the insurance has to,approve them for like more days oh A-fib,with rvr with pulmonary edema okay now,well give you an extra two days on top,of the original Three Days okay so you,literally have to go through this whole,rigmarole now to make things even worse,it doesnt always happen the hospital,doesnt always have their act together,so sometimes the person stays for five,days they only got approved for three,days so when the hospital bills the,insurance company the insurance company,pays for three days denies the last two,so theres a remaining patient balance,guess what the hospital does with those,remaining two days they automatically,build a patient and So the patients,like oh look at this a bill for twenty,thousand dollars that I was not,expecting by the way the no surprises,act doesnt stop this from happening at,all so believe me people will still get,surprise bills after this approach no,surprises act because of the denial of,bed days because of utilization,management from the insurance company,okay so theres a couple of ways that,people generally get into the hospital,one is through ER admits right they,would either admit them to Medicine,typically or sometimes they would admit,them to surgery now there the hospital,has to go through approximate its,called Insurance notification right,because youre not you dont know in,advance that Mr Smiths going to be in,the hospital they just come into the ER,and this causes a problem because people,are admitted to the hospital seven days,a week 24 hours a day these case,management nurses do not work typically,on weekends and holidays and they dont,work overnight so you end up getting,this backlog over the nights and,weekends and holidays so this whole,process of notification doesnt happen,smoothly so sometimes the patient gets,admitted and they turn around real quick,and they get discharged and the hospital,like never even notified the insurance,company that the patient was even there,but then they go ahead and they build,the insurance company anyway and then,the insurance company automatically,denies it for lack of notification so it,is it is not a smooth process okay next,up then theres theres also elective,inpatient surgeries now elected doesnt,necessarily mean optional like you could,have colon cancer and need a,hemicolectomy which is half of of your,colon taken out to remove the colon,cancer okay thats elective surgery okay,its not optional but its not emergency,surgery so its still considered,elective okay well there or even for,like that scoliosis surgery example you,got to get prior authorization and when,they prior authorize you again theyre,giving you authorization for a certain,number of days theyre not saying oh you,can just have as long of a stay in the,hospital as you want its like okay,youre approved for the scoliosis,surgery but youre only getting five,days for that and again if the persons,scoliosis surgery has a complication or,whatever you can call back and ask for,more days beyond the five oh by the way,the insurance company doesnt have to,give you more days they could be like,like no like the patient doesnt fulfill,uh requirements for hospitalization,anymore so yeah theyre in for five days,youre asking for more but guess what,were not going to prove that like we,dont have to approve that if we dont,want to so theyll deny it okay so that,begs the question then where does the,where do these numbers come from who,decides uh pneumonias three days seven,cellulitis two you know two days,scoliosis fighting like besides that,there are two major companies in America,that provide that they are interco,interqual and MCG care guidelines now,interqual anecdotally from the people,that I talk to on the insurance in the,hospital side interqual seems to be the,one thats used more frequently now,interqual interestingly is owned by,change Healthcare which was recently,bought by Optum which is owned by United,Health Group so there you go the largest,provider of utilization management,standard approval days in America is,United Health Group,intercall used to be a part of McKesson,for decades it was a part of McKesson,McKesson Fortune 10 company in America,Healthcare company and then McKesson,ended up selling it dude it was kind of,complicated but actually not too many,years ago in the somewhat recent past,that it was like five years ago they,sold it to change Healthcare and then,change Healthcare got bought by United,Healthcare so a lot of the interqual,help employees have been there and,theyve got a long history with McKesson,and youll see that theyve worked at,change healthcare for like five years,okay so this interqual says that okay,when they did this its evidence-based,all over the interqual website the,evidence base is everywhere okay they,dont say what the evidence is they have,some sort of circular framework that,describes it in general but they dont,say specifically they talk about,literature reviews but they dont say,specifically you cant say okay for,pneumonia what is the specific criteria,what are the what are the studies what,are the what is the evidence that you,used for pneumonia its proprietary you,cant find it they say that they use a,thousand doctor reviewers and its not,just excuse me clinical reviewers and,its not just doctors they also use,registered non-physicians Im not sure,what a registered non-physician is

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Utilization Review Nurse Interview Questions and Answers | Clinical Review Nurse

hey guys whats up Daniel here and,youre watching the nurse photographer,whats up nurses those following my,journey I started working in a BPO,company as a utilization review nurse so,if youre also interested in working in,a bbo company,um you can use this website the um,indeed Glassdoor,job Street monster and Linkedin by the,way Im not affiliated with those pero,you can see the job listings in those,websites,um also look I have a new mic,um it is the hyperx solocast but Im not,using this right now because I dont,have the right cord to plug it to my,camera so like right now Im using this,shotgun mic by Boya its a vlogging a,mic but right now Im using it for for,this okay so anyway,um before I share tips on how to answer,the interview questions for the,utilization review position case,management case management position,lets talk about the salary first so,usually it will depend on the company,and their clients iOS and if you search,some websites because it would range,around 50 to 70 000 and some would also,go high as 80 000 in basic but always,remember that the higher the basic the,higher the taxes okay and also that 50,to 70 000 range,um,I will talk about more about the salary,and incentives or benefits,videos because I want to focus this,video interview questions so as we all,know that one of the hardest part in,finding a new job is at the interview,okay its the most excruciating part,um there is a um two job interviews,usually,bpos for USR ends I dont know,um accounts,but yeah were going to focus on USR and,jobs and usually it is only the initial,and final interview and some might even,require tests but usually so,um Im here to help you answer those,questions and hopefully job interviews,for these,um BPO USR and jobs by the way what Im,going to share is based from my,experience from applying to different no,BPO companies here in the Philippines,and,um the questions might vary from company,to company,but what Im going to share is the usual,questions that most of them will ask all,right so I dont want to keep you guys,waiting,usually the interviews will be done,through online and phone calls so,usually pack online via Zoom or,Microsoft team depends a company,and then so basically lets start with,the initial interview so initial,interview,um they would usually just ask no,um for your credentials um usrl license,more and PHR and license,and when is the expiration date and also,they are also interested to know what,state you pass your NCLEX because for,example one company is better than,company a will Im only Creator nurses,from New Mexico or Illinois and then if,you apply,Im from Texas and they will um shoulder,the endorsement from Texas to New Mexico,Illinois,shoulder the expenses also they are,interested in knowing the expiration,date because if its expired third they,will shoulder the cost of the renewal of,your license and the CE units so win-win,situations,all right they would also ask for your,um nursing experience,um and also its an advantage if you,have a experience in the BPO company at,least six months but not necessarily,because in the um in the company where,Im working,my experience bbo and then the rest,um some accounts they know I would,prefer like one to two years of bedside,or ER experience or kahit mix mix,language and again Advantage Pokemon bbo,experience if for example you dont meet,the requirements the number of years in,a hospital,they will usually put you or assign you,in accounts that dont need,um bedside experience so thats for the,initial interview and then lets start,with the final interview,okay for the final interview these are,usually the questions that they will ask,okay this one and another more questions,by here,okay so lets um discuss them one by one,so usually,um the first question they will ask you,is tell me something about yourself,um just be yourself no,um also it would help if you,um make a script now to answer this,parallel you dont get caught off guard,no you know what you will say and one of,the advantages of having a online,interview is you can have your um laptop,in front of you and then you can just,read no with feelings,with feelings,so first off now when they ask you first,is,like tell me something about yourself,so like first sir I would like to thank,you for giving me this opportunity to be,interviewed for this nursing position I,finished nursing back in,in school and after a year I was able to,practice nursing in this government,hospital it was a good experience to,establish establish my basic nursing,knowledge and then after a year my,contract expired I worked in a BPO named,for six months and then I studied for,culinary arts or photography,and then,um lets go to the set to the next um,question,approach is tell me something about,yourself that is not included in your,resume so like,um youre gonna answer this as a someone,coming from a suguro family of doctors,or med tech or nurses,[Music],I would like to thank you for giving me,this opportunity to,um be interviewed for this nursing,position,um I came from a family of nurses I,lived with my sister suguro no or,grandmother or parents and I believe,that,um learning does not stop in school that,is why I have a lot of books here in my,room and I kept on reading a lot of,books to improve myself and I also like,to learn new skills from time to time,that is why I learned or enrolled myself,in culinary arts or photography so from,that at least Im giving you an idea,um,just be yourself no,um,and then another question the next,question is why did you leave your last,job no why did you leave your hospital,experience,um,[Music],like I had to take care of my,um Lola or Lolo because my siblings are,already in the states no Im the only,family member here in our house,during that time thats why I was forced,to leave my previous job,and another approach for this question,is um you can say that,um,no parang,you like your job in the hospital but,um I dont think that its safe to,practice nursing,anymore,um,number of patients uh,[Music],dont say those,weeds okay next question,um,why should we hire you or what can you,contribute to us advantages,um just to give you guys an idea,I will be thorough in my Approach and,assessment with the documents that are,files that I will work on,and I am able to follow the I dont know,company rules,rules and regulation of the company,is,a company so from there I think,um,um,as a person so,its just to help you guys give you guys,and at least,no um an idea on how to answer them,um,the next question is,what is your weakness,um,is public speaking so it doesnt matter,if its a group of five or ten people no,I still get uncomfortable and to,overcome this I started a YouTube,channel and a video podcast about,and up to now Im up to now Im still,developing and improving myself in,public speaking skills English,[Music],um,why go back to work in a UR or,BPO company,um,[Music],foreign,[Music],[Music],um,bedside nursing no I you want to explore,you know other fields in the BPO,industry so were gonna know again,[Music],um,okay um next question is how do you,handle stress,hospitals,okay sir I handle stress in a couple of,ways first is I stop whatever Im doing,I pray and then second is I exercise no,because running helps me focus and,prioritize on the things that I need to,finish now or to,um yeah to finish and um lastly,um you can add this no I spend time with,my family I spend time with my friends,or I spend time with my lovely wife,again make a script,with feelings,okay next question is one of the hardest,questions now,um how do you handle a rude supervisor,so for me I think this is one of the,again the hardest questions to answer I,think you will have to research on this,okay,I believe that um or I think that each,of us humans are fighting a battle that,we only know,um and I always think that the per that,person or supervisor might have problems,so I always try to be understanding,um if theres still a problem or a,conflict I would approach I would,app

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Is Utilization Review difficult to learn?

hey whats up guys welcome back to the,nursing Channel so on todays video Im,gonna answer Julie Bonners question and,Julie Bonner is one of my subscribers,who commented the question is,utilization review difficult because she,works in case management and she does,discharge planning and for those who,dont know the case management,department is split into two sections so,you can either do discharge planning or,you can do whats called a utilization,review okay and so shes interested in,jumping over to the utilization review,side of case management and shes asking,is it difficult now the answer to that,question is it is not difficult in,comparison to discharge planning I,personally feel like its easier okay,and utilization review is a good career,choice for those who are looking for a,structured schedule with no surprises,like you know when you do utilization,review you know what to expect the next,day the next day youre not gonna get,any surprises like doing bedside care,where somebody you know happens to get,into cardiac arrest and now you have a,code blue or or in discharge planning,where you know theres lack of,communication and then the patient,discharge becomes delayed for some,reason so utilization review is nice,because you dont really experience any,of those issues youre basically just,going to be looking at patient charts,and reviewing all the progress notes,reviewing the patients vital signs lab,values and the medications that theyre,scheduled on and trying to determine if,there is medical necessity for the,patient to remain in the hospital,thats essentially what a utilization,review nurse does and then once the,utilization review nurse determines that,there,is medical necessity for the patient to,remain in the hospital in a hospital bed,then they communicate that information,over to the patients insurance and,usually what happens is the utilization,review nurse will fax over clinical,information to the insurance and then,also what a utilization review nurse,does is they use and so they a,utilization review nurse determines,whether a patient has medical necessity,to remain in the hospital by using a,tool called inner core and inner qua is,a set of guidelines so that will guide,you in determining whether the patient,should remain in the hospital and so,just to focus on Julie Bonners question,is utilization review difficult no I do,not think it is difficult actually a lot,of people that have gone into the,utilization review department with no,experience say that its it could be,monotonous and tedious but Ive never,heard anybody say that its difficult or,theyre leaving the department because,its hard and they dont understand,usually people just leave the department,because they just feel like its it gets,tedious because youre youre,essentially its basically a desk job,theres very little little patient,interaction youre primarily going to be,talking with like physicians every now,and then just to get orders changed but,other than that I mean youre fixed to,your desk and your computer so if thats,something that youre looking forward to,youre looking for a job that stress,levels are lower then I would recommend,becoming utilization review nurse and,just one I just want to clarify things,just because it is an easier job,this job is still a very important job,because your clinical reviews are,necessary because without them without,you communicating with the patients,insurance the hospital is not going to,get reimbursed for the medical services,that are being provided to the patient,oftentimes when the patients insurance,doesnt receive these clinical reviews,and clinical information theyll act,there they will deny the patients,hospital stay meaning they wont pay the,hospital for the services that were,provided to the patient so anyways this,is just this is just a quick response to,her question I hope this question this,answer helps you guys out like this,video and subscribe to this channel if,you found this video helpful Ill see,you guys later

What Is Utilization Review ????

what up guys welcome back to the nursing,channel its your boy nurse sam,and right now im gonna talk to you guys,about what is utilization review,im im sure when you guys uh,heard the word utilization review you,guys were like what the heck is that,what the hell is that,youve never heard about it in nursing,they never taught you this in nursing,school,but dont worry i got you guys i got you,covered im gonna talk to you guys,exactly about what is utilization review,so utilization review in a nutshell is,basically,youre just communicating with the,patients insurance,and telling them,hey,the your your,your patient or the patient we have them,here in the hospital because,were giving them this type of treatment,and,this is the reason why you need to pay,us,you need to reimburse us for all the,care,that we provided to your member okay,so,as a utilization review nurse what you,do is,youre going to be communicating with,the patients insurance,oftentimes what youre going to be doing,is sending them clinical paperwork,youre going to send them the history,and physical youre going to send them,recent progress notes and oftentimes,youll be faxing faxing these uh,clinical notes,to the insurance fax number okay,okay besides that youre also going to,be using a software called interqual,and interqual is a software its very,simple and easy to use youre basically,just going to look up,the diagnosis that the patient came in,with for example if they came in with a,shortness of breath,or they came in with pneumonia,the software is gonna youre gonna look,for the diagnosis youre gonna look for,pneumonia and then theres little boxes,that youre gonna click and and,once you click all the boxes for that,specific diagnosis,um,the software will give you like a green,light and say hey this patient has met,the acute level of care,in other words its just telling you,that hey,you have justified why the patient needs,to remain in the hospital and then once,you once you uh,finish clicking all the boxes,youre gonna save it into the software,that way you know the insurance can look,at it later on and see okay look,this this shows me that you know the,patient still needs to be in the,hospital because they met each box for,that diagnosis which is pneumonia and so,youre going to be clicking like for,example im just going to give you an,example so once you look for pneumonia,theres going to be boxes you have to,click like,is the patient getting oxygen youre,going to look in the chart and look at,the vital signs and see if patients,getting oxygen and if they do you just,check the box,and then the other ones going to be,like the other question will be like is,this patient getting,uh antibiotics you know look at the,medications that the patient is on oh,yeah theyre on an antibiotic so then,you check that box,and so basically thats all youre doing,and youre going to be doing this for a,group of patients,this is very easy to do very,straightforward,its a its,one of the most stress-free jobs in,nursing that you can find okay,i think the reason why a lot of nurses,dont go into utilization reviews,because,they dont know what it is,and when you dont know about something,youre kind of intimidated and scared to,try something new but im telling you,guys right now,utilization review is one of the,most chill,stress-free job so if youre looking for,a structured,uh stress-free job this is the route to,go okay guys,anyways this is utilization review in a,nutshell i can go more specific and more,into detail about it but you know i just,want to give you guys a generalized idea,of what it is,anyways i love you guys im nurse sam,dont forget to like this video dont,forget to subscribe to this channel,i love you guys and im out

Non-bedside nursing: Utilization Review Registered Nurse

hey guys welcome back and if youre new,here welcome consider subscribing if you,find any of this information valuable,and in this video I want to talk about,what I do as a registered nurse so my,current position is a utilization review,registered nurse so if youre interested,in knowing more keep on watching what do,i do as a utilization review registered,nurse so like I said its more the,business side of Nursing,I dont wear scrubs I wear business,casual I work a Monday through Thursday,10 hour shifts holidays off weekends off,its like my own little heaven its like,what I wanted but what I do is in a,nutshell what I do is I follow the care,patients who are being seen by our by,other community providers so for example,if a patient for whatever reason ends up,in another hospital that is not our,hospital then we follow their care so,they have to meet specific criteria in,order for us to pay for their,hospitalization so what we do is we,follow their care and we look at their,plan and everything and we transcribe,all those clinical reviews from the,other facility into our documentation,system so that our providers know what,it is that happened in the other,hospitals so thats one thing that we do,the second thing that we do is that we,if our providers within our facility are,either referring patients out to other,community providers for whatever reason,it could be that either the patient is,requesting it we dont have those,services available or maybe our wait,times are too long and the patient needs,to be seen sooner that would be those,would be instances in which we would,send our patients,to be seen by community providers and of,course there has to be like certain,criteria that they have to meet its not,just any anybody can be set out you know,so thats the second thing that we do,and then the third thing that we do is,we do ambulance claims so that means we,review those claims that the patient,decides to call an ambulance then we,review the case as to why it is that,they called and figure out whether our,facility will be paying that ambulance,bill so thats what we do in a nutshell,theres a lot that we do and ten hours,will never be enough because its its a,lot of uh its a lot of work its,never-ending so dont think that just,because you are not doing direct patient,care that youre gonna be like bored,twiddling your thumbs because thats not,gonna happen youre gonna have to work a,regardless of what department youre at,so so far though I am really enjoying it,cuz its something new its something,completely new and Im still learning as,I go but I just wanted to share a little,bit of what it is that is out there,because you guys if you are not happy at,the bedside please know that there are,other like positions available out there,for registered nurses you dont have to,be stuck or feel like theres nothing,beyond the bedside because there are,positions that are beyond the bedside,you just have to look you have to put,yourself out there apply and just go to,the interviews and hope for the best you,know whatever is meant to be will be so,if youre thinking about leaving the,bedside or just like sometimes like if,if youre thinking of leaving the,nursing and all youve worked in is at,the bedside in a hospital setting you,guys theres other jobs out there look,beyond the bedside and I think itll,help you kind of spark that joy of like,just loving nursing again so thats why,I wanted to,Carolus like what it is that I do and we,dont do direct patient care its all,like telephone calls so yeah I just,wanted to share that with you guys,because there are positions out there,and we dont learn this stuff in nursing,school we dont learn that theres all,these like its like a different world,of Nursing that is out there its not,just a hospital so you guys if you,really want to get out get out go apply,and just do your thing like you can do,it and just put yourself out there Ill,talk to you guys next Sunday if you just,found any valuable information in this,video then subscribe and yeah Im here,every Sunday so Ill see you guys next,Sunday,bye

Improving Quality of Care through Utilization Management

good morning I actually finished,residency in 2010 so it wasnt that long,ago but I know but I was like oh wow I,happened a little bit longer than that,so for those of you that werent here,last month I gave a talk more on,clinical documentation and how to and be,more happy in what you do and so were,going to do just a little bit of that,today but most of today is going to,focus on the quality requirements with,ACGME and this could actually cover,about three or four lectures and so Im,trying to convince it down into two so,thats how Im relating it into the,happiness advantages that instead of a,health stream activity for the resident,this is a lecture instead so learning,objectives today were going to go over,what health care quality and utilization,management are identifying with a clear,health care quality pathways are so,clear is the clinical learning,environment review which is one of our,new requirements with ACGME describing,the steps that weve implemented for,here and regarding the resident quality,project and I think from what I can see,most of the residents are already,involved so that is not going to be a,big thing that I feel like I keep,getting questions about how its going,and so I wouldnt lay it out a little,bit more formally and then talk a little,bit about where my passion is and our,utilization management and then how it,relates back to quality of care so,healthcare quality was defined by the,Institute of Medicine in the 1990s and,they defined it as the degree to which,health care services for individuals and,populations increase the likelihood of,desired health outcomes and are,consistent with current professional,knowledge and so the initial goal of,quality measures is really to improve,patient care I note that in todays,healthcare world in quality measures and,things become pretty frustrating but at,the end of the day what I try to remind,myself of is the reason that they came,about was supposed to do to improve,mission technology but also because,there were bad doctors out there that,werent following standards of care and,so this whole,to a higher level of accountability so,the Institute of Medicine defines the,six different quality domains so,effectiveness which is providing care,thats based on scientific evidence and,you dont over utilize or underutilized,so theyve done a lot of studies of,Medicare and patients with Medicare and,this finding is in the billions of over,utilization not following and standard,of care and thats where this a big push,for quality of care has come from,efficiency and so you know here we talk,a lot about do they need to be here is,it and you know theyve been here for,two minutes when theyre in observation,and things like that so its Primak,surmising and efficiency of care not,waiting for IC cardiologists also not,waiting for a heart cast for three days,things like that equity so making sure,that were closing the healthcare,disparities which thats one part of,quality of care that I did not realize,was a major part so I kept saying that,the healthcare disparities was not part,of my role but that is involved with the,quality domains patient centeredness oh,we all know about patient centered care,safeties which is protecting our,patients from harm and then timeliness,obtaining the needed care without with,while minimizing delays for that group,back to your efficiency as well so this,is what we had a feel like,patient-centered care is around the,computer and the patients is a bed,thats a nice smiling happy kid in the,bed apparently but thats not really,supposed to be the goal the goal is to,see that youre more involved with your,patient so the clear pathway theres six,different things that were supposed to,make sure that we have checked off on,our box to make sure that were,providing good education and so when I,open the observation unit they did this,thing where like anything that youre,good on you put in green if youre,somewhat okay you put it in yellow and,if youre totally not there then you put,it in red so Ive continued that and a,lot of the things that I do so pretty,okay on education I could justify it but,I dont think is where it needs to be so,thats what well have lecture series,throughout and the year probably,quarterly just kind of going over a,little bit more,detail about what quality is I think,that some of the programs also provide,that within their specific program some,education on quality improvement,resident and fellow engagement and,quality improvement activities that,varies from residency to residency on,what the actual requirement is I think,er you only have to complete one project,during your entire time here for,internal medicine I think you only have,to complete one project but and its,expected that youre continuously,involved in the quality improvement,activity ecology yellow doesnt really,show up but residents or fellows receive,data on quality metrics so we arent,really doing that Im trying to figure,out what the best mode to be able to get,that information it is on ozone but we,have to be able to prove that you know,what the quality metrics are and how,things are improving and so and that,were working on how were going to,carry that off president felt engagement,planning for quality improvement of,someone in progress because and was,through the resident committees we were,doing different projects but and that,depends still be improved and in red is,really the healthcare disparity so,resident fellow and faculty member,education on reducing healthcare,disparities and engagement in the,clinical site initiatives to address,healthcare disparities so well talk,about a little bit more about that but,essentially our hospital like a lot of,hospitals and do not know what our,healthcare disparities are and,specifically to our region so we know we,have a large proportion of patients that,dont have insurance and Native American,and African American population and we,know that in school so theres been a,big push because we actually between,north Tulsa and south Tulsa about ten to,fifteen years ago they did a study and,theres actually a 10-year North,tolsons have a ten-year lower expected,life expectancy than South tolsons and,so theyre working through a lot of,different grant work to reduce that,healthcare disparity and already making,a big leap and in reducing that,healthcare disparity another stat that I,found was that forty percent of total,population is in north Tulsa but only,four percent of,first were there and so theres been a,big push to move a lot more physician,offices into that area to provide the,care so youll be hearing a lot more,about that Clara will do site visits and,I think our first sight is it wont be,for another year but when they come they,give us ten days notice that theyre,coming and this is three ACGME and so,well be doing mock site inspections and,things like that and dr. alice alice is,actually the clear person thats in,charge of all of it and then im in,charge of quality component so the,things that theyll ask regarding,quality from what Ive read from other,institutions is our residents I was,exactly familiar with the clinical sites,priorities for quality improvement and,so the quality of department is to,developing a priority project list which,will be sent out so that you guys will,have that information and the rest of it,is all in the planning stages because,they really didnt have those,requirements with being away previously,ok so just very briefly you know I see,by a show of hands through all is,involved Im going to do two different,questions in the hospital committing,quality projects okay and yeah you are,use a micro video still getting underway,on ours and then whos involved in,projects through their residency okay I,knew ER cardiology,okay so forming the team what we set up,for here was just that each committee,hospital committee the faculty and that,are the committee chair would be the,lead of that team were seeing a lot of,problems with that and so well b

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