About this Learning Activity

Utilization Management 101: Foundations - Essential Practices

Utilization Management 101: Foundations of Utilization Management Practice is a 90-minute, self-paced course that gives you that map. You will learn what utilization management is, why it exists, how prior authorization, concurrent review, and retrospective review actually work, and how medical necessity decisions are made and defended. You will see how national standards from NCQA and URAC shape UM programs, how federal rules like CMS-0057-F are changing prior authorization, and how denials and appeals move through the system. The learning activity is for a mixed audience: both payer-side and provider-side professional. No prior UM experience required. Whether you are new to a health plan UM department, a provider organization navigating payer requirements, or a leader who needs to understand what your UM team does all day, this course gives you the foundation to speak the language and follow the process with confidence.

What You Will Learn

• Utilization Review
• Prior Authorization
• Concurrent Review
• Retrospective Review
• Medical Necessity

• Define foundational practices for utilization management.
• Distinguish prior authorization, concurrent review, and retrospective review, and match each to real-world examples.
• Describe standard and expedited turnaround-time expectations for UM decisions.
• Outline the required elements of a denial notice and the basic steps of the appeals process.

Who Should Attend

This course is designed for professionals who lead or contribute to case management activities. Ideal participants include:

• Clinicians, care coordinators and case managers
• Utilization management leaders and professionals
• Quality improvement and performance improvement leaders and professionals
• Subcontractors, partners, and delegates of utilization management teams

Faculty

Kelly Cavin, BSN, MA, MBA 

Kelly Cavin is the Assistant Vice President, Customer Experience at NCQA. In this role, she provides strategic leadership for customer education, learning experiences, and customer engagement initiatives that support health care quality improvement across the industry. Kelly oversees the development and delivery of educational programs designed to help health plans, provider organizations, quality leaders, and other health care professionals understand and implement NCQA standards, accreditation programs, performance measurement initiatives, and quality improvement strategies. With a background spanning nursing, education, business, and health care operations, Kelly leads cross-functional teams responsible for instructional design, educational program development, customer experience improvement, and accredited continuing education. She plays a key leadership role in ensuring NCQA's educational offerings align with evolving industry needs and support interprofessional learning, quality improvement, and organizational excellence. Under her leadership, NCQA continues to expand innovative learning pathways, virtual education programs, and customer-focused solutions that advance the quality of health care.

Vince Pereira, MHA 

Vince Pereira, MHA is a Senior Manager at the National Committee for Quality Assurance in Washington, DC with over 13 years of experience in health policy, strategic implementation, and interprofessional training. In his current role, Vince leads initiatives that enhance organizational readiness of health plans, health systems, community-based organizations, and their partners. Mr. Pereira is a Fellow of the Academy for Healthcare Management (FAHM), Certified Professional in Healthcare Quality (CPHQ), and holds a Master of Health Administration from the George Mason University.

Continuing Education

This is a non-accredited activity.
This course grants 1 optional Continuing Education Unit (CEU) points for PCMH Certified Content Experts.

*Please note – You must complete the entire program to be eligible for total number of contact hours.

Disclosure of Relevant Financial Relationships

The National Committee for Quality Assurance (NCQA) endorses the Standards of the Accreditation Council for Continuing Medical Education which specify that sponsors of continuing medical education activities and presenters at and planners for these activities disclose any relevant financial relationships either party might have with commercial companies whose products or services are discussed in educational presentations.

For sponsors, relevant financial relationships include large research grants, institutional agreements for joint initiatives, substantial gifts, or other relationships that benefit the institution.  For presenters or planning committee members, relevant financial relationships include the receipt of research grants from a commercial company, consultancies, honoraria, travel, or other benefits, or having a self-managed equity interest in a company; or having an immediate family member or partner with such a relationship.

Disclosure of a relationship is not intended to suggest or condone bias in any presentation but is made to provide participants with information that might be of potential importance to their evaluation of a presentation.

Relevant financial relationships exist with the following companies/organizations:

Faculty:

Kelly Cavin: None
Vince Pereira: None

Additional Planning Committee Members:

This program was developed by NCQA staff.
This program received no commercial support.