Case Manager doing Utilization Management

[ASSEDO]

A few years ago, or hospital paid big bucks for a consultant to come in to evaluate our department. The consultant company informed our managment that one person could do both jobs. Now our department is cross-trained and one nurse does both specialities. However, or audits suck. My question: in your facility, does the Case Manager/discharge planning also do the Utilization part? With the demands of insurance companies and Medicare regulations, we have so much to do we are making mistakes..we are now failing..our audits.

[MiMiRNTampabay]

I am currently doing home health care arrangements/DME/etc......Would like to branch out into UR.....Seems UR is more likely to allow me to do some travel nursing in the future......Any ideas on how to get certified or trained in UR? I would like to find some resources......

[Mijourney]

I am currently doing home health care arrangements/DME/etc......Would like to branch out into UR.....Seems UR is more likely to allow me to do some travel nursing in the future......Any ideas on how to get certified or trained in UR? I would like to find some resources......

Try http://www.mckesson.com/en_us/McKesson.com/For+Payors/Private+Sector/Professional+Education/Certified+Professional+Utilization+Review+%2528CPUR%2526%2523153%253B%2529.html

See if that helps any. Best wishes.

[Tangerine Lipgloss]

I do both. I do UR for a particular unit and then CM for three other areas. I work for insurance. It gets hectic as I feel torn between the two. We are short staffed and I am covering one CM area almost since I started. I am new to CM as well. Every day I feel like the floor is going to give way underneath me, but my boss assures me that I am doing well.

I find the corporate world very strange and I'm not sure I will stay. I think I'd rather do CM in the hospital, at least I am onsite and will know what is going on. I'm trying to give myself a year to learn, so we'll see.

[debnky]

I don't understand how they keep nurses working, 60hrs and getting paid for 40 that is crazy!

[Katie82, RN]

I think there are some healthcare settings where this would work, but the hospital is not one of them. I believe that discharge planners should understand UM, but every discharge planner I have ever worked with has had much too heavy a caseload to perform chart reviews as well. I am currently working as a case manager in Medicaid, and our program is adding a lot of UM to our load. I understand this, because our primary focus is to insure that patients are receiving adequate services. Many of my coworkers are functioning as Social Workers/Mentors. The major goal of our program is to save the State money in Medicaid expenditures while insuring that patients receive appropriate care. Each month I receive several reports from the State involving ER Utilization, Inpatient stays, Disease Management disparities, etc. I feel that I am in a much better position to achieve our goals by working from these lists than by spending my day picking up prescriptions from pharmacies and transporting patients to appointments. I focus on finding other people to do these jobs and focus on what is costing us money...

[NRSKarenRN, BSN, RN]

One of the things our homecare agency has done to help several hospitals in our area with combined UR/CM depts, is to have an onsite homecare liaison. Once need identified for homecare, onsite liaison assess the patient, shows patient list of homecare agencies (most choose ours), writed referral, order DME, IV infusion, labs draws, etc freeing up a few moments in your day...