Case Manager doing Utilization Management

  1. 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.
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  2. 17 Comments

  3. by   kimmykng
    i'm doing utilization review and my company is going to try to cross train us in tcm. i don;t know how this can be done, as right now, i get between 80 - 100 files a month. Out audits are always very high, but with the addition of tcm... well, i don;t know.. the UR nurses are NOT looking forward to this transition..
  4. by   CaseManager1947
    I work in the hospital. and we follow our caseload, do all the referrals for home heatlh, dme etc. + continued stay reviews. We do have a two nurse team that gets the initial clinical in , to get the precert, then we have to follow up with the concurrants. I have 27 patients on my load today.

    MMC
  5. by   DaveMac
    Being overwhelmed seems to be par for the course now. I work in a small county hospital. I am a one man department. I do Discharge Planning, Utilization Review, Infection Control, and Employee Health. I am also expected to also help manage the nurses, take nurse manager call, take patients and/or assisted the floor, ER, and OR/Endo if the DON feels it is needed. How am I to get my work done. I gave up with being caught up months ago. It takes till 10 or 11 to get done with insurance. By this time the hospitalist is on the floor and he hords the charts so I have a hard time doing InterQual on every patient (DONs orders). To top this off, The DON will call meetings at 1530 0r 1600. Now I start at 0700. There are also regular scheduled meetings through out the week at either 1300 or 1400, about 3 times a week. When I mention that I could use another nurse, I am told that our census is too low. Sometimes I feel like I am being set up to fail.
  6. by   ASSEDO
    Quote from DaveMac
    Being overwhelmed seems to be par for the course now. I work in a small county hospital. I am a one man department. I do Discharge Planning, Utilization Review, Infection Control, and Employee Health. I am also expected to also help manage the nurses, take nurse manager call, take patients and/or assisted the floor, ER, and OR/Endo if the DON feels it is needed. How am I to get my work done. I gave up with being caught up months ago. It takes till 10 or 11 to get done with insurance. By this time the hospitalist is on the floor and he hords the charts so I have a hard time doing InterQual on every patient (DONs orders). To top this off, The DON will call meetings at 1530 0r 1600. Now I start at 0700. There are also regular scheduled meetings through out the week at either 1300 or 1400, about 3 times a week. When I mention that I could use another nurse, I am told that our census is too low. Sometimes I feel like I am being set up to fail.

    After all that, I hospitals expects you to walk on water too!! It is very flustrating and there is no hope in site.....hospitals expect more that a human can deliver and if we let something accidently fall through the cracks, we get our tails chewed off. It just not ethically right...Good luck.
  7. by   BahaMamamaRN
    We do Interquall reviews weekly our Census is usually around 28 for two Nurse Case Managers. We coordinate care conference weekly, provide families and pt w/ weekly updates. Call insurance for continued stay. Luckily I have a social worker who orders equipment and facilitates the discharge ordering home health and IV therapy for home .She also calls and schedules the patients follow up appointments. It is constant but it sounds like you have your hands full with helping out on the floor and performing other nursing duties. I'd look for another job who valued my case management expertise better.
  8. by   edgwow
    I do admission interquals and reviews, weekly medicare for the difficult placements and those awaiting nursing home grants for LTC or those without insurance that can not have a safe discharge , since so many of our pts. come from poor backgrounds, homelessness, drug, alcohol, no family support. I do concurrent review and interqual usually every 2-3 days and determinations from insurers. I call every insurer with review. I do discharge planning for equiptment, IV home infusion, home nursing, PT, many for pts that live more than 50 miles away. I have 20 patients every day, I have discharge planning rounds an hour and weekly meetings. Work 60, get paid for 40, never a day goes by where I am completely caught up in my work, although I do try. If someone does not have insurance I have more forms to fill out, I am resposible for seeing every pt. within 3 days of admission to assess possible discharge needs. This is a physical impropability. Eat lunch about 2 days a week, feel guilty for taking a potty break and answer phone calls from discharged patients without primary care doctors that have a problem and need to talk to a doctor.
    :typing This looks like me on a Monday, happily typing away on my laptop, but by Friday, my smile is turned upside down. Oh, How I love my job!!!!!
  9. by   CaseManager1947
    Oh how times have changed... now I do trauma cm; same hospital, just a different service line... This last week I had 34 patients.. still do all the dme, hhc, home o2 etc. I often work > 60 hrs a week, get paid for 40 plus they keep laying new tasks at our feet every day. Of course we walk on water !!! That is in your job description... other duties as assigned!! HE HE
  10. by   Luv Nursing
    Question for the Case Managers praticing in the state of Maryland. At our hospital, our Social Worker (official title is Patient Care Coordinator) has just been informed by the new HIM director, that she has been doing her job wrong. In addition to discharge planning, she is our UR person and has been using Interqual (or the equivelant), however the HIM director has told her she is to no longer to use interqual, but to use DRG's and Coding. The HIM director is new, from a huge hospital in Texas and has from the day she has arrived, told everyone that everything we are doing is wrong....despite our excellent JCAHO surveys and such.

    She wants the PCC to fax a census to the HIM's office, with the pt's admitting dx, and appropriate codes for coding. She refuses to let the PCC order interqual updates for her book, nor will she send the PCC to any official training for this new format she's insisting on. ( The HIM director has told the PCC to come down to her office and she'll train her whenever the PCC has time...). This HIM director has caused major conflict within the hospital over several issues, and does things off the cuff (like firing our transcription service that has been great for us the past several years and hiring who she used in Texas....without prior notice, discussion, etc.) She actually believes that because we are a "small hospital" JCAHO will be more forgiving, especially if we don't "intentionally do something". ( You know, we didn't mean to amputate the wrong limb, or we didn't mean to have the wrong patient identifiers on the H&P's, etc.)

    What format are UR's in Maryland using? Any advice I can give our PCC would be greatly appreciated b/c she is about to walk out!

    Thanks!!
  11. by   DaveMac
    Quote from edgwow
    I do admission interquals and reviews, weekly medicare for the difficult placements and those awaiting nursing home grants for LTC or those without insurance that can not have a safe discharge , since so many of our pts. come from poor backgrounds, homelessness, drug, alcohol, no family support. I do concurrent review and interqual usually every 2-3 days and determinations from insurers. I call every insurer with review. I do discharge planning for equiptment, IV home infusion, home nursing, PT, many for pts that live more than 50 miles away. I have 20 patients every day, I have discharge planning rounds an hour and weekly meetings. Work 60, get paid for 40, never a day goes by where I am completely caught up in my work, although I do try. If someone does not have insurance I have more forms to fill out, I am resposible for seeing every pt. within 3 days of admission to assess possible discharge needs. This is a physical impropability. Eat lunch about 2 days a week, feel guilty for taking a potty break and answer phone calls from discharged patients without primary care doctors that have a problem and need to talk to a doctor.
    :typing This looks like me on a Monday, happily typing away on my laptop, but by Friday, my smile is turned upside down. Oh, How I love my job!!!!!
    Seems like we work at the same type of place. Where you do InterQual every 2-3 days, I was directed by the CNO (DON) to do them every day of the week, including weekends. She has hired 3 nursing students to help on the weekends. They have other jobs when they are here also. The DONs mother was in a hospital in another city recently and the DON was told that InterQual should take less than 15 minutes, even for new admits. It takes longer than that here, 15 - 60 minutes for a new admit. Granted we are not computer charting anything yet and every thing is paper. My question is does this is taking me to long, if so, how can it be speed up? Still have to do the insurances, placements, DMEs, etc, etc. Monday :typing Wednesday :throcomp: Friday :crash_com Friday Night :beercuphe
  12. by   CardioTrans
    I work for a large teaching facility, and there is only one service that has separate CM's and UR. The rest of us do it all. We do have social workers, but the one that I have on my service also has other services that she covers. So its like I have 1/4 of a social worker.

    I do the IQ daily, unless I know the patient is going to be on service for awhile. In that case, I do it every other day or every 3rd day. Also calling the insurance companies.... I also have to meet each patient/family, take patient phone calls, weekly CM meetings, weekly service meetings, and a separate weekly meeting with the head of the service. I do help line up home health, LTC, LTAC, or whatever discharge disposition that is going to be needed.... again I have 1/4 of a social worker. Add in education for patients, nurses, and the residents and my days are pretty full.
  13. by   debnky
    Seems as though you case managers have a great deal of responsibilities to say the least. Can I ask how you obtain such a position, is there special training and is the pay more than say: Psych Nurse which is what I am. Thanks!
    Debbie
  14. by   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......

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