Utilization Management Course Work Samples

Published: 2021-06-18 06:11:39
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Category: Management, Health, Patient, Nursing, Medicine, Organization, Health Care, Disease

Type of paper: Essay

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What are the challenges faced by MCOs regarding practice variations? What do you think can be done to meet these challenges?
Variations in healthcare programs are expensive. Overutilization, underutilization, and improper utilization are challenges that MCOs face. MCOs should adhere to procedures and protocols using the established standards by organizations example the national committee for quality assurance (NCQA).

Differentiate between the three main processes of institutional utilization management

Determine the main purpose of each process of institutional utilization management. Which process do you think is the most important, and why?
The direct admissions’ purpose is to create timely attendant for the outpatients that come to the hospitals. The Surgical admissions’ purpose is to determine the severity of the patient’s disease and the saving of an individual’s life. Lastly emergency department admissions purpose is to determine if the hospital is capable of handling the medical issue (kongstvedt, 2013).
Direct admission is the most important process among the rest, which is because, at this level, the hospital is made aware in handling the patient received by the hospital.

Research the role of the utilization management nurse.

Commonly known as utilization review, their main role is ensuring the patient gets paramount care there is in order to achieve the best possible outcome. They also determine the medical appropriateness as well as the necessity given to a patient (kongstvedt, 2013).

Explain the functions of the utilization management nurse, and compare and contrast the information from that organization.

Utilization management (UR) nurses observe the way needy individuals cared for, and determine the appropriate medication prescribed to the needy individuals. The UR nurses are also to note that all needy individuals are cared for in the best way possible and in the most cost-effective manner. According to the National committee for quality assurance (NCQA), if all healthcare systems in America performed their duties very well then the cost of health care in America could significantly drop (kongstvedt, 2013).

Explain your understanding of disease management and case management. What in your opinion are one major similarity and one major difference between the two types of management?

Disease management is the process of taking care of a person suffering from complex medical problem or with an enervating condition due to. Usually, a group of professionals that include nurses, therapists, and specialists take care of the individual. This group must have support from family members and friends (kongstvedt, 2013). Case management on the other hand encompasses,
Planning, accessing, and evaluating of the options required to meet the wants and necessities of an elderly individual (kongstvedt, 2013). Case management requires resource mobilization, advocacy, as well as communication between people seeking help for an individual in need of medical attention.

The major similarity between case management and disease management is that, both champion and work for the benefit of a needy individual. The two advocate for patient safety, good care, and change of health-related behaviors. However, they differ in; disease management looks at the process of taking care of a chronically debilitated individual while case management looks mostly at the best way an individual is going to be taken care off. Mostly, disease management deals with chronic medical issues such as asthma, arthritis, and diabetes while case management looks at elderly people as well as people with extensive chronic illnesses.

What is the purpose or mission of these professional organizations?

Their purpose is to provide an environment that is safe and healthy, capable of healing individuals. They aim at giving the best health care that nature the afflicted in the society.

What standards do these organizations set for certification or membership?

How do these organizations define disease or case management and do they differ from the text definitions?
The two organizations agree that a standardized way of defining case management is non-existent. Rather, they see case management as a collaborative process of planning, coordinating, monitoring, and implementing options as the options required in meeting the needs of clients. Their definition does not differ with the text definition of disease or case management.


Kongstvedt, P. (2013). Essentials of managed health care. Burlington, MA: Jones & Bartlett learning.

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