Follow one Medicare Advantage patient from prior authorization, through a complicated hospital stay and a denial, to the records that arrive 40 days after discharge. In one hour you will know what a utilization management (UM) nurse actually does, what the 2026 rules require, and whether this work is for you.
- 1.0 contact hour · Provider approved by the California Board of Registered Nursing, CEP 18046
- Built and taught by a working Lead Prior Authorization Nurse · Evidence and regulations current to 2026
- Self-paced · Certificate on completion · Accepted for RN renewal in 33 states plus Washington, D.C.
Price line: $29 · one-time purchase · lifetime access to this course version
Course Description
Utilization management is the clinical checkpoint behind every prior authorization, every continued-stay review, and every “medical necessity” conversation between a hospital and a health plan. This one-hour course teaches it the way it is practiced: on a case.
You will follow Mr. Barney Bypass, a fictional 71-year-old Medicare Advantage member, from his surgeon’s request for coronary artery bypass graft (CABG) surgery through the plan nurse’s prospective review, the post-operative complications that push his stay past the authorized days, the clinical updates the hospital never sent, the lack-of-information denial that followed, and the retrospective (post-service) review of the records that arrived 40 days after he went home. At each checkpoint you will see the regulatory clock that applies, the criteria the reviewer opened, and the exact note the nurse wrote.
Along the way you will learn how utilization management differs from case management, how MCG Care Guidelines and InterQual Criteria are built and how each reads the same chart, what the 2026 federal and California rules require of plans and reviewers (CMS-0057-F turnaround times, the Contract Year 2026 Medicare Advantage rule on approved admissions, physician review of adverse decisions, and limits on artificial intelligence in review), and what the 2025–2026 evidence says about UM’s effect on cost, quality, and access.
The course is designed for registered nurses considering a move into utilization management, nurses in their first months of a UM, prior authorization, or concurrent review role, and case managers and hospital utilization review staff who work with payers. All acronyms are defined on first use. Every lesson ends with an APA-formatted reference list.
Upon completion, participants earn 1 contact hour of continuing education, approved by the California Board of Registered Nursing (CEP18046).
Course Objectives
At the end of this course, the participant will be able to:
- Define utilization management (UM) and utilization review (UR), and distinguish UM from case management (CM) by purpose, core question, and metrics.
- Sequence prospective, concurrent, and retrospective (post-service) review along a single Medicare Advantage inpatient episode, naming the regulatory clock and the nurse’s deliverable at each checkpoint.
- Compare MCG Care Guidelines and InterQual Criteria in structure and daily application, and state what neither criteria set may decide under Medicare Advantage coverage rules.
- Describe the registered nurse’s responsibilities in concurrent review and payer–provider collaboration, including when a case must be routed to physician review.
- Explain how UM affects cost, quality, and access, using evidence published in 2025 and 2026.
Course Format & Learning Experience
- Format: 100% online and self-paced in your student account. Three narrated video lessons and three reading lessons; pause and return any time. Works on desktop, tablet, and phone.
- Time: About 65 minutes. 1.0 contact hour is awarded (a contact hour is at least 50 minutes of organized learning).
- Assessment: 10 scenario-based questions drawn from the case. A score of 80% (8 of 10) is required. Unlimited attempts; rationales are shown after each attempt.
- Course evaluation: A short evaluation survey follows the assessment. The California Board of Registered Nursing requires it; your certificate is valid only after you submit it.
- Certificate: Available for immediate download after the assessment and evaluation are complete. Keep it with your renewal records.
- Access: Lifetime access to this course version, including the reference lists for every lesson
Who Should Take This Course?
This course is for you if:
- You are a bedside or non-UM registered nurse and want to know what utilization management really involves before you rewrite your resume.
- You just started a UM, prior authorization, or concurrent review job and want the vocabulary, the review checkpoints, and the two notes every reviewer writes, in one sitting.
- You are a case manager, discharge planner, or hospital utilization review nurse who deals with health plans and wants to understand how the reviewer on the other end is thinking.
- You are a licensed clinician who is not an RN and want a clear, current picture of how UM works. You are welcome; CE credit is issued for RNs.
Skip this course if you already perform concurrent review or prior authorization daily and want depth on criteria application, payer communication, compliance, and career strategy. That is the 5.0-contact-hour flagship course, Getting Started in Utilization Management for RNs: Medical Necessity, Communication, Compliance, and Professional Pathways, or the UM Mastery Bundle.
What you will be able to do after this hour
- Explain medical necessity in one sentence, and separate it from the coverage question, the way interviewers expect.
- Place any review on the right checkpoint (prospective, concurrent, or retrospective) and name the clock that applies: 7 calendar days or 72 hours for prior authorization, 24 hours for an urgent concurrent decision, 30 to 60 days for post-service.
- Describe what MCG and InterQual each contain, how a reviewer navigates them, and why “criteria not met” is a referral to a physician, never a denial.
- Write the two signature nurse work products: a concurrent clinical update that a plan can approve without a phone call, and a physician routing note whose first line says why the case is there.
- Talk credibly about the 2026 rules: faster prior authorization clocks, protected inpatient approvals, physician review of adverse decisions, and the limits on artificial intelligence in utilization review.
What’s inside
| Lesson | Title | Format | Minutes |
| 1 | What Utilization Management Is, and Why It Exists | Narrated video | 11 |
| 2 | Utilization Management vs. Case Management: Same Chart, Different Question | Reading | 8 |
| 3 | Prospective, Concurrent, and Retrospective Review, One Patient at a Time | Narrated video | 12 |
| 4 | MCG and InterQual, Inside the Criteria | Reading | 10 |
| 5 | The Nurse’s Role in Concurrent Review and Payer–Provider Collaboration | Narrated video | 10 |
| 6 | What UM Does for Cost, Quality, and Access | Reading | 7 |
| Final assessment (10 scenario questions) and course evaluation | Quiz | 7 | |
| Total | 65 |
Instructor Bio
Polina Obshchanska, BSN, RN – is a Lead Prior Authorization Nurse on a Medicare and Medi-Cal prior authorization team, where she reviews cases and coaches new reviewers. She is an MSN candidate in Nurse Administration and the founder of MedScholaria Consulting, Inc., a California Board of Registered Nursing–approved continuing education provider (CEP 18046) focused exclusively on utilization management education for nurses. Her path into UM ran through hospice RN case management, and she built this course for the nurse she was in her first two weeks on a review queue.
Provider statement and disclosures
Provider approved by the California Board of Registered Nursing, Provider Number CEP18046, for 1 contact hour.
MedScholaria Consulting, Inc. has no commercial support for this course and no conflict of interest to disclose. MCG Care Guidelines and InterQual Criteria are discussed as licensed products; MedScholaria has no relationship with either vendor and does not provide access to either product. This course is educational and is not legal advice; regulations change, and learners should verify current requirements with the Centers for Medicare & Medicaid Services, their state, and their employer.
State acceptance
MedScholaria’s California BRN-approved contact hours are accepted for registered nurse license renewal in 33 states plus Washington, D.C. Some states have mandatory topic requirements that this course does not satisfy on its own. Check your state on our state acceptance page, (last checked September 2026) and confirm with your board of nursing.
Refund & Cancellation Policy
Course purchases are non-refundable once course access has been granted. If a technical issue prevents course access, contact polina@medscholaria.com within 7 days of purchase and we will resolve it or issue a refund at our discretion. Should MedScholaria Consulting, Inc. cancel the course, a full refund will be provided within 10 business days.
From RNs who completed our courses
What UM Nurses Say
Verbatim feedback from RNs, submitted through MedScholaria course evaluations and testimonial forms. Across 52 course evaluations, 92% agreed the content was relevant to their nursing practice.
Thoroughly enjoyed this class; it provided me with valuable insights into the world of utilization management. I learned a great deal, gaining information that I can apply in this field. The material was presented in a clear and understandable way. I also want to extend my gratitude to Polina, not only for designing the course but also for her guidance and support, which boosted my confidence as I transition into the utilization management arena. I will definitely recommend this class, as it addressed my questions…
Completed: UM Mastery Bundle (all three courses)
Sep 12, 2026
Ive been trying to get a job in Utilization Review as an RN, but unfortunately, I don’t have the needed experience, so I found this course to learn all about the job. It has really helped me understand the role.
Completed: Getting Started in Utilization Management: Tools, Trends, and Opportunities for RNs
Sep 29, 2026
I found this course to be an informative look at a position in nursing that allows the use of all former bedside skills and clinical knowledge. Introductory information was abundant in UM, and the comparisons and differentiations between Case Management and Utilization Management were extremely well presented. Real-world examples helped to increase my understanding of the information. I would encourage nurses to take this interesting CEU class.
Completed: Getting Started in Utilization Management: Tools, Trends, and Opportunities for RNs
May 26, 2025
I’m new to UM, and this course broke everything down in a way that was easy to follow. It’s a great starting point for beginners.
Completed: Getting Started in Utilization Management: Tools, Trends, and Opportunities for RNs
Sep 18, 2026
One stop shop for all basics required to understand the role in detail, and the use of tools and workflows related to potential job opportunities.
Completed: Getting Started in Utilization Management: Tools, Trends, and Opportunities for RNs
Apr 19, 2026
Course information presented clearly and concisely. Self-paced format allows for great flexibility. If one is curious about the role of a nursing professional in the Utilization Management, I recommend this course as a great starting point.
Completed: Getting Started in Utilization Management: Tools, Trends, and Opportunities for RNs
Jun 9, 2025
UM is more sophisticated than most staff think!
Completed: Getting Started in Utilization Management: Tools, Trends, and Opportunities for RNs
Jun 4, 2026
I appreciate the simplicity of this course and look forward to taking more courses immediately.
Completed: Getting Started in Utilization Management: Tools, Trends, and Opportunities for RNs
Jan 10, 2026
Thank you for this informative and affordable course! I learned a lot!
Completed: Getting Started in Utilization Management: Tools, Trends, and Opportunities for RNs
Jan 26, 2026
Good for novice who wants to know more about UM.
Completed: Getting Started in Utilization Management: Tools, Trends, and Opportunities for RNs
Jun 7, 2026
Very informative and presented in a clear manner.
Completed: Getting Started in Utilization Management: Tools, Trends, and Opportunities for RNs
Apr 15, 2026
This course exceeds my expectations! As a UR nurse transitioning into a leadership role, I found the content practical, organized, and applicable to daily work. Whether you’re new to utilization management or looking to strengthen your utilization management knowledge, this course is perfect. You can tell a lot of thought and expertise were utilized throughout the course. I highly recommend it to anyone interested in learning about utilization management. It is an excellent investment in your professional growth.
Completed: Getting Started in Utilization Management for RNs: Medical Necessity, Communication, Compliance, and Professional Pathways
Jun 30, 2026
This was interesting and encouraging! It lessened my fear that AI will take over my job. I can see there’s an important place for both the medical professional and AI collaborating together for the patients.
Completed: The Role of Artificial Intelligence in Utilization Management: Enhancing Healthcare Decision-Making
Jun 27, 2026
This is an excellent introductory course to AI and its role in UM. It is essential in today’s healthcare and tech climate for healthcare providers to keep up with the fast evolving world of UM. This course has been informative and easy to understand. Highly recommend to any practitioners who are currently integrating AI into their work rules.
Completed: The Role of Artificial Intelligence in Utilization Management: Enhancing Healthcare Decision-Making
May 6, 2025
I liked the short videos, interesting content, and feedback requested. It is very relevant.
Completed: The Role of Artificial Intelligence in Utilization Management: Enhancing Healthcare Decision-Making
Jun 27, 2026
What UM Nurses Say
Verbatim feedback from RNs, submitted through MedScholaria course evaluations and testimonial forms. Across 52 course evaluations, 92% agreed the content was relevant to their nursing practice.
Thoroughly enjoyed this class; it provided me with valuable insights into the world of utilization management. I learned a great deal, gaining information that I can apply in this field. The material was presented in a clear and understandable way. I also want to extend my gratitude to Polina, not only for designing the course but also for her guidance and support, which boosted my confidence as I transition into the utilization management arena. I will definitely recommend this class, as it addressed my questions…
Ive been trying to get a job in Utilization Review as an RN, but unfortunately, I don’t have the needed experience, so I found this course to learn all about the job. It has really helped me understand the role.
I found this course to be an informative look at a position in nursing that allows the use of all former bedside skills and clinical knowledge. Introductory information was abundant in UM, and the comparisons and differentiations between Case Management and Utilization Management were extremely well presented. Real-world examples helped to increase my understanding of the information. I would encourage nurses to take this interesting CEU class.
I’m new to UM, and this course broke everything down in a way that was easy to follow. It’s a great starting point for beginners.
One stop shop for all basics required to understand the role in detail, and the use of tools and workflows related to potential job opportunities.
Course information presented clearly and concisely. Self-paced format allows for great flexibility. If one is curious about the role of a nursing professional in the Utilization Management, I recommend this course as a great starting point.
UM is more sophisticated than most staff think!
I appreciate the simplicity of this course and look forward to taking more courses immediately.
Thank you for this informative and affordable course! I learned a lot!
Good for novice who wants to know more about UM.
Very informative and presented in a clear manner.
This course exceeds my expectations! As a UR nurse transitioning into a leadership role, I found the content practical, organized, and applicable to daily work. Whether you’re new to utilization management or looking to strengthen your utilization management knowledge, this course is perfect. You can tell a lot of thought and expertise were utilized throughout the course. I highly recommend it to anyone interested in learning about utilization management. It is an excellent investment in your professional growth.
This was interesting and encouraging! It lessened my fear that AI will take over my job. I can see there’s an important place for both the medical professional and AI collaborating together for the patients.
This is an excellent introductory course to AI and its role in UM. It is essential in today’s healthcare and tech climate for healthcare providers to keep up with the fast evolving world of UM. This course has been informative and easy to understand. Highly recommend to any practitioners who are currently integrating AI into their work rules.
I liked the short videos, interesting content, and feedback requested. It is very relevant.
Frequently asked questions
Is this course right for me if I have never worked in utilization management? Yes. It assumes clinical nursing knowledge and no UM experience. It is the course to take before you decide whether to invest in the full 5.0-contact-hour program.
I already work in UM. Will I learn anything? If you are in your first few months, yes: the 2026 rules, the criteria comparison, and the two notes are what most orientations skip. If you have been doing concurrent review or prior authorization for a year or more, the flagship course is the better fit.
Does this course give me access to MCG or InterQual? No. Both are licensed products. The course teaches how each is built and how reviewers use them, so you can work with whichever your employer licenses.
How long do I have to finish? There is no deadline. Most learners complete it in one sitting of about an hour.
What do I need to pass? 80% on a 10-question scenario assessment, with unlimited attempts, followed by the course evaluation the California BRN requires.
Will my state accept this contact hour? It is accepted for RN renewal in 33 states plus Washington, D.C. Check your state on our state acceptance page and confirm with your board.
Is the patient in the case real? No. Mr. Barney Bypass is a fictional composite created for teaching. The clinical details, clocks, and regulations are real.
What happens after I finish? You download your certificate. If you want to go deeper, the flagship course covers medical necessity, communication, compliance, and professional pathways in 5.0 contact hours, and the UM Mastery Bundle adds the 3.0-contact-hour course on artificial intelligence in UM.
Course Pricing & Enrollment
- Standard Price: $29
Questions? Contact Us: polina@medscholaria.com
One hour, one patient, every checkpoint. If you want to know what utilization management is before you commit to it, or you want to walk into your new review queue already speaking the language, start here.
Already know you want all three courses? The UM Mastery Bundle includes this course, the 5.0-contact-hour flagship, and AI in Utilization Management (9.0 contact hours total) at one price.
