Certified Revenue Cycle Representative (CRCR) Practice Exam

Utilization review is primarily conducted by which type of personnel?

1. Administrative staff

2. Professional healthcare personnel

3. Insurance company representatives

4. Independent auditors

The correct answer is: Professional healthcare personnel

Utilization review is a process aimed at evaluating the necessity and appropriateness of healthcare services, procedures, and facilities. This process is predominantly conducted by professional healthcare personnel, such as nurses and physicians, who possess the clinical expertise necessary to assess the medical necessity of proposed treatments and the effectiveness of the current care being provided to patients. Professional healthcare personnel understand the clinical standards and guidelines that govern patient care, which enables them to make informed decisions about the appropriateness of care provided. Their training and experience allow them to analyze patient records, treatment plans, and other healthcare documentation to ensure that the services rendered are aligned with best practices and medical necessity criteria. While administrative staff may assist in coordination and documentation, insurance company representatives focus on policy adherence and coverage aspects, and independent auditors offer an external review perspective, none possess the same level of clinical insight as professional healthcare personnel when it comes to conducting comprehensive utilization reviews. This ensures that the process is carried out with a higher degree of accuracy and reliability concerning the quality of care provided.