Programme overview
Introduction:
Hospital case management and utilization review covering length of stay and discharge planning is a 5-day course for case management, utilization review, bed management and revenue cycle teams that ends with a Case Management Programme Design and KPI dashboard for a case hospital. Hospitals lose bed capacity and income when admissions lack level-of-care evidence, continued-stay reviews slip, discharges stall for non-clinical reasons and payers deny days that cannot be defended. Nominees already review inpatient stays, coordinate discharges or handle authorisations and work through case studies built on census and denial data. CoreConcept Training Center delivers this hospital case management course.
Course Objectives:
- Organise a hospital case management service by selecting a staffing model, role boundaries and a caseload assignment method
- Apply evidence-based admission and continued-stay screening criteria and run prospective, concurrent and retrospective utilization reviews
- Prepare payer authorisation requests and utilization review notes that record level-of-care decisions and escalations
- Track avoidable days by cause and owner and set expected discharge dates that shorten length of stay
- Prevent and appeal level-of-care denials and reduce readmissions through structured transitions of care
- Report case management performance on a KPI dashboard and design a case management programme with its review workflow
Target Audience:
- Staff who assess inpatient stays against admission and continued-stay criteria and record review decisions
- Staff who coordinate discharge plans, post-acute referrals and family meetings for inpatients
- Staff who allocate beds, track the daily census and escalate delayed discharges
- Staff who obtain payer authorisations, answer review requests and work level-of-care denials
- Staff who compile length-of-stay, avoidable day and readmission reports for hospital management
Course Outline:
Day 1: Hospital Case Management Foundations and Service Baseline
- Hospital Case Management Functions Across Advocacy, Coordination and Transitions
- Integrated, Dyad and Triad Case Management Staffing Models
- Case Manager, Social Worker and Physician Advisor Role Boundaries
- Unit-Based Versus Service-Line Caseload Assignment Methods
- Case Management Baseline Audit of Census, Reviews and Discharges
Day 2: Level-of-Care Criteria and Utilization Review Methods
- Evidence-Based Admission Screening Criteria for Inpatient Level of Care
- Observation Versus Inpatient Status Determination Workflow
- Prospective, Concurrent and Retrospective Utilization Review Cycles
- Continued-Stay Review Frequency and Secondary Review Escalation Rules
- Physician Advisor Referral Pathway for Unresolved Level-of-Care Cases
Day 3: Payer Authorisation, Avoidable Days and Discharge Planning
- Payer Authorisation Requests With Clinical Summary Submission Standards
- Utilization Review Note Template and Review Decision Log
- Avoidable Day Coding by Cause, Owner and Delay Category
- Expected Date of Discharge Setting at Multidisciplinary Rounds
- Discharge Planning Assessment With Post-Acute Placement Referrals
Day 4: Denials Prevention, Appeals, Readmissions and Case Management Metrics
- Concurrent Denial Prevention Through Peer-to-Peer Review Requests
- Level-of-Care Denial Appeal Letter With Supporting Review Evidence
- Readmission Risk Screening and Post-Discharge Follow-Up Call Protocol
- Transitions of Care Handover With Medication and Appointment Checklists
- Case Management KPI Set for Stay, Denials and Readmissions
Day 5: Case Study: Case Management Programme Design for a Case Hospital
- Case Hospital Census, Avoidable Day and Denial Data Review
- Review Workflow Design From Admission Screening to Discharge
- Avoidable Day Reduction Actions With Named Owners and Deadlines
- Case Management KPI Dashboard With Targets and Data Definitions
- Case Management Programme Design Completion and Peer Defence
Skills You Will Gain:
- Caseload Model Design
- Level-of-Care Screening
- Concurrent Stay Review
- Payer Authorisation Handling
- Avoidable Day Analysis
- Discharge Barrier Resolution
- Denial Appeal Drafting
- Readmission Risk Screening
Why Attend This Course:
- Deliver a Case Management Programme Design with review workflow and KPI dashboard to the director of case management and the hospital operations committee
- Decide when a stay meets continued-stay criteria, needs secondary review or should be referred to a physician advisor
- Avoid denied days, unplanned readmissions and bed blockages caused by late reviews and stalled discharge plans
- Share review templates, avoidable day codes and appeal letter structures with ward case managers and authorisation staff
Conclusion:
Back at work, the participant gives the director of case management and the hospital operations committee a Case Management Programme Design that sets the staffing model, review frequency, escalation rules, avoidable day codes, discharge planning steps and denial appeal routes. Management uses it to approve caseload assignments, physician advisor cover and authorisation desk procedures, while unit case managers track the KPI dashboard at daily bed meetings. After the first quarter, the committee should compare length of stay, avoidable days, denied days and readmissions against the baseline and revise the steps that did not move them.
Frequently Asked Questions (FAQ):
What should participants know before the hospital case management and utilization review course?
Participants should already review inpatient stays, plan discharges, manage beds or handle authorisations and denials. No clinical treatment is taught. Bringing anonymised census reports, avoidable day logs or denial letters helps them apply the case work to their own hospital.
How does hospital case management and utilization review differ from a general hospital operations course?
It concentrates on individual inpatient stays: level-of-care criteria, review cycles, authorisations, avoidable days, discharge planning, denials and readmissions. General hospital operations courses cover governance, theatres, quality and finance across the whole hospital and treat discharge as one topic among many.
Why do avoidable days matter in hospital case management and utilization review?
Avoidable days are bed days with no clinical reason to stay, usually caused by delayed tests, placements or decisions. Coding them by cause and owner shows which delays to fix first, frees beds and reduces days a payer may refuse to cover.
What do participants take back from the hospital case management and utilization review course?
Participants take back a Case Management Programme Design with a review workflow, escalation rules, avoidable day codes, an appeal letter structure and a KPI dashboard covering length of stay, denied days and readmissions that they can adapt to their own hospital.