Optimizing Utilization Management in Professional Case Management Practice

Source: CMSA Today BY MICHAEL B. GARRETT, MS, CCM, CVE, CPCHE Utilization management, also called utilization review, has been present in the U.S. healthcare system for several decades. Initially, utilization management programs were focused on addressing overutilization, meaning excessive use of healthcare services that lead to waste in the system without realizing significant improvements in […]

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Introducing the CMSA Microcredential in Utilization Management: Elevating Practice, Demonstrating Value

Source: CMSA Today BY DR. COLLEEN M. MORLEY, DNP, RN, CCM, CMAC, CMGT-BC, ACM-RN, FCM, FAACM As healthcare continues to evolve toward value-based care, the expectations placed on case managers — particularly in utilization management (UM) — have grown significantly in both scope and complexity. Today’s case manager is no longer simply coordinating care; they

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Health Information Technology in Case Management: Advancing the CMSA Standards of Practice to Navigate Modern Healthcare Challenges

Source: CMSA Today BY PAUL BORJA, RN, PHN, DHA, DNP, EdD, DBA, PhD, CCM, ACM, CMAC, CNML, CMGT-BC, CMCN, CDONA, FAACM, FACDONA, FSIEN, FADLN INTRODUCTION Healthcare delivery has evolved considerably over the past two decades due to advances in technology, regulatory changes, value-based reimbursement, and increasing patient complexity. As healthcare systems become more interconnected, case

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Artificial Intelligence and Innovation in Case Management Nursing

Source: CMSA Today BY HEATHER KELLY, MSN, RN, BCPA, CPC Case management nurses operate at the intersection of clinical care, utilization management, and patient advocacy. As healthcare systems become more complex, case managers are increasingly tasked with managing high-risk populations, coordinating care across settings, and addressing social and behavioral determinants of health, all while navigating

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Life Care Planning for Healthcare Professionals: An Overview

Source: CMSA Today BY ANNE GOWING, RN, CRRN, CNLCP®, MSCC, FIG MCP-C, FIG LCP-C INTRODUCTION As healthcare grows increasingly complex, so too does the need for professionals who can provide comprehensive, forward-looking life care plans for individuals with chronic illness, catastrophic injury, or disability. Life care planning is a specialized discipline integrating medical, vocational, and

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Peanuts and Case Managers

Source: CMSA Today BY MICHELLE BRUSIO, MSN, RN, CCM One of my favorite guilty pleasures is collecting and enjoying Charles Schulz’s Peanuts. From the earliest comic strips to the beloved television specials and treasured collectibles, some classics truly stand the test of time. Each character was inspired by someone in Schulz’s life, and together the

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Every Heart Matters: Empowering Underserved to Manage High Blood Pressure

Source: CMSA Today BY HEIDI STEINHEBEL, RN BSN CCM Hypertension impacts Black African Americans 26% more often than other racial/ethnic groups, and approximately 83% of Black adults with high blood pressure do not have it under control, even while on medications. Deaths related to high blood pressure occur twice as frequently in Black Americans compared

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The Human Algorithm: Integrating Artificial Intelligence (AI) into Professional Case Management Practice While Upholding the CMSA Standards of Practice

Source: CMSA Today BY CATALINA KHALAJ, PMHNP-BC, MSN, RN, CCM, ACM, CMGT-BC—A case manager with experience across ambulatory care, acute care, managed care, and population health. ABSTRACT In an era of unprecedented technological advancement, professional case managers stand at the intersection of innovation and compassion. Artificial intelligence (AI) and digital tools offer powerful capabilities to

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Beyond the Authorization: Navigating the Evolving Challenges of Utilization Management

Source: CMSA Today BY JANET COULTER, MSN, MS, RN, CCM, FCM INTRODUCTION Mention utilization management (UM), and many healthcare professionals immediately think of prior authorizations, medical necessity reviews, documentation requirements, and coverage determinations. It may not be the most glamorous area of healthcare, but utilization management sits at the very heart of ensuring patients receive

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