Chabot College
2002
Removed Fall 2010
Course Outline for Health 54
UTILIZATION MANAGEMENT, RISK MANAGEMENT & MEDICAL STAFF CREDENTIALING
Catalog Description:
54 - Utilization Management, Risk Management and Medical Staff
Credentialing
1 unit
Study of utilization management in the health care environment, with emphasis on clinical pathways,
regulatory requirements, reimbursement issues and case management. Risk management is the process of
evaluating potentially compensable events that could result in an injury or financial loss. Credentialing is the
process by which medical practitioners are evaluated for quality and control of services provided. Each topic
will investigate the history, regulatory requirements and methodologies associated with each of these quality
assurance activities. Strongly recommended: Health Information Technology 50 or equivalent. 1 hour.
[Typical contact hours: 17.5]
Prerequisite Skills:
None
Expected Outcomes for Students:
Upon completion of the course the student should be able to:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
discuss overview of the utilization management, risk management and medical staff credentialing
functions;
cite important Joint Commission, Federal and State regulatory requirements;
discuss the importance of the Hospital and Medical Staff Bylaws in information management;
describe various methodologies for monitoring each specialty;
demonstrate knowledge of generic screens, clinical indicators, severity of illness indicators, intensity
of service indicators, and clinical pathways;
utilize diagnosis and procedures to identify DRG's and establish length of stay;
discuss and critique how managed care and PPS has altered utilization in healthcare;
calculate case mix and evaluate case mix for components of the health care community;
describe several 3rd party payers and the impact on utilization and risk management;
perform various quality assurance activities/studies using selected criteria;
verify and validate information related to each specialty using a health record;
distinguish between the various components of each function;
define the unique vocabulary of each medical specialty;
discuss hospital organization, medical staff organization and credentialing;
describe claims management, occurrence screening, appointment and reappointment activities and
peer review;
perform risk management and credentialing activities.
Course Content:
1.
Utilization management
a.
Overview of utilization management
b.
Regulatory requirements
c.
Hospital and medical staff bylaws
d.
Methodologies for monitoring
e.
Screens and indicators
f.
Identification of DRG's
Chabot College
Course Outline for Health 54, page 2
Fall 2002
Course Content - continued:
2.
3.
g.
Length of stay
h.
The effect of managed care and PPS
i.
Case mix
j.
Impact of third party payers
k.
Quality assurance activities
l.
Using the health record to verify and validate information
m.
Components of utilization management
n.
Vocabulary of utilization management
o.
Occurrence screening
p.
Appointment and re-appointment activities
q.
Peer review
Risk management
a.
Overview of risk management
b.
Regulatory requirements
c.
Hospital and medical staff bylaws
d.
Methodologies for monitoring
e.
Screens and indicators
f.
Case mix
g.
Impact of third party payers
h.
Quality assurance activities
i.
Using the health record to verify and validate information
j.
Components of risk management
k.
Vocabulary of risk management
l.
Claims management
m.
Risk management activities
Medical staff organization and credentialing
a.
Overview of medical staff credentialing functions
b.
Regulatory requirements
c.
Hospital and medical staff bylaws
d.
Methodologies for monitoring
e.
Screens and indicators
f.
Case mix
g.
Using the health record to verify and validate information
h.
Components of medical staff and credentialing
i.
Vocabulary
j.
Hospital organization
k.
Medical staff
l.
Credentialing processes and activities
Methods of Presentation:
1.
2.
3.
4.
Lecture
Demonstration
Discussion
Record review
Chabot College
Course Outline for Health 54, page 3
Fall 2002
Assignment and Methods of Evaluating Student Progress:
1.
Typical Assignments
a.
Research
1)
Compare and contrast hospital case mix
2)
Find bench marking data in a variety of sources
b.
Review of records
c.
Reading
d.
Oral presentation
1)
Locate articles on cases
2)
Relate cases to events of negligence
e.
Library research
2.
Methods of Evaluating Student Progress:
a.
Quiz
b.
Oral presentation
c.
Final examination
Textbook(s) (typical):
Health Information: Management of a Strategic Resource - Abdelhak, Mervat, 1996
Special Student Materials:
None
Revised 2/6/02