Apply prospective, concurrent and retrospective review to patient stays at the correct level of care.
Healthcare & Pharmaceutical Management
Utilisation Review and Medical Necessity Determination
Prepares utilisation review nurses and physician advisors to apply medical necessity criteria consistently and to manage payer review across the patient stay.
🗓️Duration5 training days
📚Content4 modules · 8 sessions
🎓On completionAccredited attendance certificate
About the programme
Course Overview
Utilisation review sits at the point where clinical judgement, payer rules and patient flow meet, and when it is applied inconsistently patients are held at the wrong level of care, physicians face repeated payer disputes, and organisations absorb avoidable delay days. This course works through prospective, concurrent and retrospective review, and the admission criteria that separate inpatient, observation and outpatient status. It covers applying evidence-based medical necessity criteria consistently, recognising when a case needs secondary physician review, and preparing physician advisors for peer-to-peer calls with payer medical directors. Later modules address managing disputed determinations, distinguishing administrative from clinical denials, and integrating utilisation review with discharge planning so that continued-stay days reflect clinical need rather than placement delay. Teaching uses case scenarios, criteria application exercises and escalation pathways drawn from acute hospital settings. Participants leave able to apply utilisation review consistently and to defend determinations under payer scrutiny.
Expected Learning Outcomes
Distinguish inpatient, observation and outpatient status using recognised admission criteria.
Apply evidence-based medical necessity criteria consistently across comparable presentations.
Recognise when a case requires secondary physician advisor review and prepare it accordingly.
Prepare physician advisors for peer-to-peer review calls with payer medical directors.
Distinguish administrative denials from clinical medical necessity denials at the point of dispute.
Align utilisation review timing with discharge planning to reduce avoidable delay days.
Who Should Attend
Utilisation review nurses working prospective, concurrent and retrospective review.
Physician advisors supporting medical necessity and level-of-care decisions.
Case managers coordinating discharge planning with utilisation review timing.
Hospital medical directors overseeing utilisation review committee governance.
Payer relations staff managing prior authorisation and peer-to-peer processes.
Revenue integrity staff tracking necessity denials linked to utilisation review decisions.
Course Modules
Select any module to see its sessions and points.
01The Utilisation Review Process and Levels of Care
2 sessions · 8 points
Session 1Prospective and Concurrent Review
- Apply prospective review to prior authorisation requests before scheduled admissions or procedures.
- Conduct concurrent review of inpatient stays against evidence-based level-of-care criteria.
- Distinguish inpatient, observation and outpatient status using recognised admission criteria.
- Document the clinical rationale that supports each level-of-care determination.
Session 2Retrospective Review and Audit
- Run retrospective review of closed cases to test consistency with medical necessity criteria.
- Identify patterns of over-utilisation or under-utilisation across service lines or physicians.
- Reconcile retrospective review findings against concurrent review decisions on the same cases.
- Feed retrospective review findings into physician education and criteria training.
02Applying Medical Necessity Criteria
2 sessions · 8 points
Session 1Criteria Application and Clinical Judgement
- Apply evidence-based medical necessity criteria consistently across comparable clinical presentations.
- Recognise when a case falls outside standard criteria and requires secondary physician review.
- Document the specific clinical indicators that justify a medical necessity determination.
- Distinguish medical necessity determination from coverage or benefit-plan eligibility questions.
Session 2Physician Advisor and Secondary Review
- Define the physician advisor's role in resolving cases that nursing-level review cannot approve.
- Prepare case summaries that give the physician advisor the information needed for a timely decision.
- Escalate complex or borderline cases through a defined secondary review pathway.
- Track secondary review turnaround time as a driver of length of stay and patient experience.
03Payer Interaction and Peer-to-Peer Review
2 sessions · 8 points
Session 1Working with Payer Utilisation Management
- Submit prior authorisation and continued-stay requests with the clinical detail payers require.
- Track payer response times and escalate authorisation delays that affect patient care.
- Prepare for peer-to-peer review calls between the treating physician and the payer's medical director.
- Record the outcome of payer interactions to support any subsequent appeal.
Session 2Managing Disputed Determinations
- Distinguish administrative denials from clinical medical necessity denials at the point of dispute.
- Prepare the clinical evidence package needed to challenge an adverse necessity determination.
- Coordinate with case management and revenue integrity teams on disputed determinations.
- Track overturn rates on appealed necessity denials to identify criteria or documentation gaps.
04Integrating Utilisation Review with Case Management
2 sessions · 8 points
Session 1Aligning Utilisation Review and Discharge Planning
- Coordinate utilisation review timing with discharge planning to avoid avoidable delay days.
- Identify patients whose continued stay reflects social or placement barriers rather than clinical need.
- Collaborate with case managers on alternate level-of-care placement for appropriate patients.
- Document delay reasons in a way that separates clinical, operational and social causes.
Session 2Programme Governance and Performance Reporting
- Establish a utilisation review committee that oversees criteria, escalation and physician engagement.
- Monitor utilisation review productivity, turnaround time and determination accuracy.
- Benchmark length-of-stay and denial-avoidance performance against comparable organisations.
- Report utilisation review outcomes to medical staff leadership and finance on a recurring cycle.
What the participant receives
4 course modules
A structured syllabus
8 training sessions
across 5 days
32 detailed points
Applied, detailed content
Accredited attendance certificate
On completing the programme
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