differences between UM and CM

Specialties Case Management

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Specializes in psych, ltc, case management.

Hello friends!

My latest job is working for an insurance company as a utilization management RN. My job essentially consists of working in the field and assessing members for home care potential and medical day care appropriateness, then conducting the authorizations and paperwork that goes along with my decision.

This is my first job out of direct patient care. It is so much better than working bedside but thEre are still some cons to it if course. I'm wondrering if I would like CM better but I feel like I dont have a good grasp of what it entails. Ive asked some coworkers who are CM but they arent very specific. From what they say its mostly phone calls with education for members and filling out questionaires to determine level of care.

Is there more to it? Have any of you worked in both? Do you like one better than the other? Why?

Please excuse any typos! (New phone and I'm still figuring it out)

Thanks everyone!!!

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Specializes in ED, ICU, MS/MT, PCU, CM, House Sup, Frontline mgr.

OP: Your post reads as if you only perform UM/UR on your job. This does not make you less of a Case Manager. UM is Case Management.

To answer some of your questions... I have a PT job, where I only perform UM/UR on a case load of active and inactive patients. The reports I develop are sent to insurance companies so that the hospital for which I work receives proper payment. On the other hand, I have a full-time job, where I perform UR and I have an active case load, where I must assess patients in-person and make clinical decisions regarding proper admission and dispositions of patients from the hospital setting (which is what I think you mean by "CM").

The difference between my two jobs is that I am actively involved with patient care in my Full-Time position rather than my Part Time position. Specifically, I discuss cases with the healthcare teams, perform UR, and I advocate and intervene (when problems arise) with medical courses of treatment for patients in real-time, as well as, facilitate proper discharge.

Many times I find that my FT job is more stressful than my PT job because of the stressors related to what I encountered working as a bedside nurse; customer service applied to crazy and/or violent patients and family members. Good luck.

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Specializes in Med surg, cardiac, case management.

Some places combine UM and CM. I work for a place where they're separate.

Our UM nurses call hospitals for clinical information on patients, write notes on the patients, and approve or deny hospital stays. They have UM reps who handle routine approvals of procedures and doctor's visits.

Our CM nurses (all telephonic, no field work) call new members and perform assessments and see if they need any assistance. We help people deal with illnesses, find doctors and specialists, give members information on disease, assist them in getting medications and procedures and medical equipment and follow up with them after hospitalizations.

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