Keeping Clinicians at the Bedside: A System-Wide Utilization Management Strategy That Protects Revenue and Compliance

Utilization management has changed. Managed care requirements are growing more complex. Yet, in many health systems, UM is still treated largely as a clinical function, leaving clinicians to balance patient care with increasingly demanding payer-facing work. The result: avoidable denials, delayed payments, rising UM nurse costs, and clinical resources pulled away from the bedside.

In this session, we’ll explore how one of New York State’s largest hospital networks adopted a system-wide, modern utilization management strategy to advance its revenue and compliance goals. Attendees will learn how the health system strengthened visibility across the UM continuum, strengthened denials management, and better aligned patient-focused care with payer requirements. The session will also examine how appropriate patient status decisions, outcome-focused metrics such as Net Inpatient Realization (NIR), disciplined application of the Two-Midnight Rule, and structured payer escalation can help reduce avoidable revenue loss while keeping clinical teams focused on patients.

Key Takeaways: 

• Learn why healthcare utilization management priorities have shifted, and why treating UM as solely a clinical function may no longer fit the work.
• Understand how complex managed care requirements can pull clinicians away from bedside responsibilities and affect financial outcomes.
• Explore the impact of avoidable denials, delayed payments, rising UM nurse costs, and disruptions to case management.
• Discover how improving visibility into the next step for each case can support authorization, reimbursement, and denials management.
• See how a modern utilization review management strategy can balance payer and administrative needs with a focus on patient care.