Yes there is a nurse work environment for gimpy (in body, not mind and I’m not making light or making fun of physical ailments, I myself fall into this category due to a back injury)….or…older (should I say more experienced)…or… for nurses who would just like a change to a non-clinical nursing position. One of the avenues for this is Utilization Review/Utilization Management Nursing.

Usually, the UR/UM nurse must have a minimum of five years clinical nursing and a bachelor degree for consideration of this position. Opportunities exist at hospitals, acute rehabs, outpatient care facilities, health insurance providers, and other managed care organizations, etc.

It is really a rewarding position, unfortunately this article will be a “short version” of what the UR/UM nurse position fully entails. Familiarity with CMS (Medicare) rules/guidelines and Insurance “criteria for approval of care” is helpful.  It is imperative that the UR/UM nurses have strong clinical, communication, and computer skills, as they must convey and correlate information with Physicians, Insurance Liaisons, Case Managers, and even the patients themselves.

What does the job involve, you ask? Mainly ensuring the level of care a patient receives (Inpatient Critical, Inpatient Intermediate, Inpatient Acute, Outpatient with Observation Services, or strictly Outpatient) provided by the “Healthcare Entity” is appropriately billed and approved for payment and done within the contracted time-frame. This process involves analyzing the patient’s severity of illness and intensity of service, then comparing them to a pre-determined criterion (usually InterQual or Indicia).

Once the clinical analysis/comparison is completed by the providing facility’s UR/UM nurse, the information, along with the request for a pre-certification authorization of payment, is passed on to the insurance company for their UR/UM nurses to review for approval or denial. This initial consideration for approval is just the beginning of the process. There is an on-going effort for approval of the continuing medical treatment, as long as the patient requires it.

For the UM/UR nurse who can recognize the appropriate level of care provided and promptly send the correct criteria with supporting clinical to the payor to justify that level of care, then approval for the request can be quickly processed and a prompt payment received. This, of course ensures a timely positive financial impact for the medical provider. Unfortunately, it doesn’t often happen this smoothly….not in our imperfect world.

Skilled nursing experience and judgment is invaluable for the UR/UM nurse, so employing a seasoned UR/UM nurse is advantageous, especially If there is disagreement between the parties on the appropriate billing level of payment. Recognizing that the higher level of care was not only provided, but medically necessary, the provider’s UM/UR nurse can refuse to accept a lower level of care offer or the denial of payment by the insurer’s UM/UR nurse. AND, VICE-VERSA… from the Insurer’s stand point….you wouldn’t want to pay for a higher level of care, when a lower level of care is more appropriate.

As you can see, the UR/UM position is not as “hands-on” as a floor or ICU clinical nurse, but success requires clinical knowledge and determination to ensure the patient, health care provider, and the payor are in sync with the Level of Care Provided and Level of Care Payment.

If the parties cannot come to a timely agreement, then, further steps are initiated, such as…a formal re-consideration, involving the Physicians for Peer-to-Peer discussions with the Insurance company’s Medical Director, or sending the account for medical appeal. If the initial levels of appeal do not render a consensus, it can cost both entities additional time and money for lawyers and court expenses to solve through adjudication, thus producing a negative effect on the bottom-line for each party.

Let’s face it, if an insurance company can persuade the healthcare provider to accept payment based on a lower level of care instead of the higher level one the medical facility provided, then the insurer’s bottom-line has the positive impact instead of the care-providing facility. Unfortunately, I have personally witnessed abuse where the Insurance Company dispensed a Denial for Acute Inpatient Level of Care payment, though the patient clearly had that level of care need and treatment…thus, the imperfect world.

Some hospitals combine their Utilization Management position to include Case Management (which ensures continuity of care needs once a patient is discharged). Does your Health Care Facility combine or separate the two?  Let us know how your facility handles Utilization Management!

***The American Managed Care Nurses Association (AAMCN) offers a home study prep course (CEU approved) that could look good on a resume for nurses wanting to transition into the specialty of managed care that includes utilization review. AAMCN

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