Common use of Utilization Management (UM Clause in Contracts

Utilization Management (UM. Director who is an Ohio-licensed registered nurse or a physician with a current unencumbered license through the Ohio State Medical Board preferably with a certification as a Certified Professional in Health Care Quality (CPHQ) by the National Association for Health Care Quality (NAHQ) and/or Certified in Health Care Quality and Management (CHCQM) by the American Board of Quality Assurance and Utilization Review Providers. The UM Director is responsible for overseeing the day-to-day operational activities of the Utilization Management Program in accordance with state guidelines. The UM Director shall have experience in the activities of utilization management as specified in 42 CFR 438.210. Primary functions of the Director of Utilization Management position are to ensure: i. There are written policies and procedures regarding authorization of services and that these are followed; ii. Consistent application of review criteria for authorization decisions; iii. Decisions to deny or reduce the amount of services are made by a health care professional who has appropriate clinical expertise in treating the enrollee's condition or disease; iv. Notices of adverse action meet the requirements of 42 CFR 438.404; and v. All decisions are made within the specified allowable time frames.

Utilization Management (UM. Director who is an Ohio-licensed registered nurse or a physician with a current unencumbered license through the Ohio State Medical Board preferably with Board. This person may have a certification as a Certified Professional in Health Care Quality (CPHQ) by the National Association for Health Care Quality (NAHQ) and/or Certified in Health Care Quality and Management (CHCQM) by the American Board of Quality Assurance and Utilization Review Providers. The UM Director is responsible for overseeing the day-to-day operational activities of the Utilization Management Program in accordance with state guidelines. The UM Director shall have experience in the activities of utilization management as specified in 42 CFR 438.210. Primary functions of the Director of Utilization Management position are to ensure: i. There are written policies and procedures regarding authorization of services and that these are followed; ii. Consistent application of review criteria for authorization decisions; iii. Decisions to deny or reduce the amount of services are made by a health care professional who has appropriate clinical expertise in treating the enrollee's condition or disease; iv. Notices of adverse action meet the requirements of 42 CFR 438.404; and v. All decisions are made within the specified allowable time frames.