RN's and USRN's (Utilization Review and Management, Precertification, medical claims, and Peer-review)

[akosiprincejan]

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UM is the evaluation of the appropriateness and medical need of health care services procedures and facilities according to evidence-based criteria or guidelines, and under the provisions of an applicable health benefits plan. Typically, UM addresses new clinical activities or inpatient admissions based on the analysis of a case, but may relate to on-going provision of care, especially in an inpatient setting.

UM describes proactive procedures, including discharge planning, concurrent planning, pre-certification and clinical case appeals. It also covers proactive processes, such as concurrent clinical reviews and peer reviews, as well as appeals introduced by the provider, payer or patient. A UM program comprises roles, policies, processes, and criteria.
UM roles may include: UM Reviewers (often an RN with UM training), a UM program manager, and a Physician Advisor. UM policies may include: the frequency of reviews, priorities, and balance of internal and external responsibilities.
UM processes may include: escalation processes when a clinician and the UM reviewer are unable to resolve a case, dispute processes to allow patients, caregivers, or patient advocates to challenge a point of care decision, and processes for evaluating inter-rater reliability amongst UM reviewers.
UM criteria may be developed in-house, acquired from a UM vendor, or acquired and adapted to suit local conditions. Two commonly used UM criteria frameworks are the McKesson InterQual criteria, and the Milliman Care Guidelines.

[kaboang2007]

up tani ninyo..

[vienzel]

which companies in cebu who hires these positions? do u know?

[oAizeNo]

HCCa, Accenture, EXL, UHG, not sure about QBE.