Introduction

This website is a work in progress. Its content will evolve as topics are introduced or refined. Some sections are fully developed while others are in its beginning stages or not started but will launch in the near future. Throughout this website, readers will encounter many underlined words. These words are hyperlinked so that readers can click onto them to view additional information or reference sources.  

Readers can subscribe to get periodic updates and/or provide suggestions as to what medical management topics they would like to see on this site. 

For now, Learn UM Skills would like to provide some clarity to its readers by explaining some key terms and concepts.

The Meaning of Medical Management

This website targets individuals who are interested or currently working in the medical management arena. The umbrella term, medical management is typically used to describe clinical programs within a health plan setting. Medical management programs typically consist of multiple clinical-based programs that help validate, manage and ensure services are appropriate, within established benefit packages, and is medically necessary, effective, and cost-efficient throughout the continuum of care. Medical management strategies are designed to improve the quality and outcome of healthcare delivery. Clinical-based programs include, but are not be limited to: utilization/resource management, case/care management, disease/population management, and pharmacy management. While each clinical program may have different functions, they all have similar goals.

The Usage of “Patient” and “Member”

Throughout this website, readers will encounter words such as, “patient”, “member” “client”, etc. All of these words refer to a person but the word used to describe the person varies based on its association:

• Patient is used when associated with a physician or other healthcare provider in a clinical setting such as a hospital, physician’s office, outpatient clinic, etc.
• Member/Enrollee/Subscriber is used when associated with a health plan or insurance entity.
• Client is used when associated with a person seeking or receiving professional services.
• Recipient/Beneficiary is used when associated with a funding source, such as a Medi-Cal recipient or Medicare beneficiary.

Primary Focus on Medi-Cal vs Medicaid

Learn UM Skills is based in California. Therefore, this website contains more information about California's version of Medicaid, the Medi-Cal program than about the Federal Medicaid program. However, links to the Medicaid program are provided for readers to learn more about the Federal program.

Comments About Critical Thinking

The medical management arena benefits from critical thinkers who are able to identify and address issues related to healthcare services. 

Moreover, good critical thinking skills aid in the Utilization Review (UR) decision-making process. UR not only involves validating medically necessity of services, it also includes thorough understanding of the case. This is why it is essential to apply critical thinking skills when performing UR activities, to “see the whole picture”.

Critical thinking is that mode of thinking — about any subject, content, or problem — in which the thinker improves the quality of their thinking by skillfully analyzing, assessing, and reconstructing it. Critical thinking is self-directed, self-disciplined, self-monitored, and self-corrective thinking. https://www.criticalthinking.org/pages/our-conception-of-critical-thinking/411

Key critical thinking components are:

1. Observation (identify a problem, concern, issue)
2. Analysis (evaluate facts, data or information)
3. Inference (draw a conclusion)
4. Communication (explain and discuss the problem and explore solutions)
5. Problem solving (implement the most optimal solution and evaluate effectiveness)

Insights

Throughout this website, readers will encounter “Insight”. Insights are perspectives of Learn UM Skills.