Question

Define Utilization Review and discuss the role of the case manager in the Utilization Review process and how critical pathways are used.

Answer 1

Ans) According to URAC, an accreditor of health care organizations, utilization management is "the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of the applicable health benefits plan, sometimes called 'utilization.

- The aim of the utilization review and quality management is to determine the appropriateness of the health care services provided.

- Utilization review is the process of making sure health care services are being used appropriately. The goal of utilization review is to make sure patients get the care they need, that it's administered via proven methods, provided by an appropriate health care provider, and delivered in an appropriate setting.