The Role of Artificial Intelligence in Utilization Management – Enhancing Healthcare Decision-Making

Earn 3 CE Contact Hours – CA BRN Approved | Intermediate Level | 2026 Edition

Course Overview

AI is no longer on its way into utilization management. It is in the queue you work today, and the rules around it changed in 2026. This intermediate-level course is built for nurses who already do UM, prior authorization, or case management and need to know what these tools actually do, where they fail, and what federal and state rules now require of the people who use them.

Every module was rebuilt in September 2026 from peer-reviewed research, government sources, and health plan and vendor materials published in 2025 and 2026, including CMS-0057-F, California SB 1120, the HHS Office of Inspector General’s 2026 Medicare Advantage guidance, and the American Nurses Association’s 2026 AI in Nursing Practice findings. Vendor claims are labeled as company-reported so you learn to tell evidence from marketing.

What you will work through

• Module 1: AI foundations for UM: machine learning, natural language processing, and how these tools reach a recommendation
• Module 2: AI in prior authorization, predictive analytics, and workflow automation, including the CMS WISeR Model and the nH Predict litigation
• Module 3: Legal frameworks and bias: SB 1120, Section 1557, HIPAA, and how an algorithm discriminates without using race
• Module 4: Real-world integration and what comes next: nurse-led case studies from Yale New Haven Health and Mayo Clinic Health System, the 2027 FHIR API deadline, agentic AI, and gold carding

Course Objectives

By the end of this course, you will be able to:

• Explain how machine learning, NLP, and generative AI are applied in utilization management and prior authorization.
• Evaluate AI-driven medical necessity, predictive analytics, and automation tools against the evidence, and distinguish independent findings from company-reported results.
• Analyze federal and state requirements that govern AI in coverage decisions, including CMS-0057-F, SB 1120, and Section 1557.
• Identify algorithmic and automation bias and apply safeguards that keep the clinician accountable for every adverse determination.
• Apply implementation, validation, and governance strategies to AI tools in your own UM setting.

Who This Course Is For

Practicing UM, utilization review, prior authorization, and appeals nurses; RN case managers; and UM leaders, compliance, and quality professionals who are evaluating or already using AI-supported review. You should be comfortable with core UM concepts such as medical necessity criteria, concurrent review, and the appeal process. New to UM? Start with the free UM Career Starter Kit or the UM Fundamentals course.

Course Format & Learning Experience

• 100% online and self-paced. About 3 hours across four modules.
• Reading blocks, narrated presentations, clinical decision points, and a written reflection on a real health plan case.
• Knowledge checks in every lesson and a 20-question final quiz with rationales.
• Reference lists for every lesson, formatted in APA 7th edition, so you can verify every source.
• BRN-approved certificate for 3 contact hours on completion.

Course Pricing & Enrollment

• Standard Price: $129
• Also included in the UM Mastery Bundle (9 CE hours).
• Questions? polina@medscholaria.com

Instructor Bio

Polina Obshchanska, BSN, RN – Lead Utilization Management Nurse, Continuing Education Provider, and MSN student in Nurse Administration. Polina has almost 10 years of experience in healthcare, including hospice, case management, utilization management and healthcare quality, and is the founder of Medscholaria Consulting, Inc., a BRN-approved CE provider focused on empowering nurses through relevant, timely, and nationally impactful education.

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.

BRN Provider Statement

“Provider approved by the California Board of Registered Nursing, Provider Number CEP18046, for 3 contact hours.”