hello all! i'm new to this site. i found you while i was doing a search for an answer re: interqual, when i saw this question.
i've been an lvn in texas nearly 30 years and have been in the case mgt. arena for over 12 of those. i started out as a dc/dme coordinator in a home health office and worked my way thru the cm/um maze as a utilization management/discharge planner for a medical management company who, at the time specifically advertised and recruited for lvn's. i then became an onsite reviewer for 5 hospitals, all within a few miles of each other, for a medicare replacement hmo. one of the hospitals i was where i was onsite recruited and hired me for their first 'employed' medical appeals nurse. they recruited me because i was constantly assisting their cm's on the various units w/what items to look for to make the day(s) meet criteria to avoid denials. i also helped explain the appeal process, so if i had no choice but to issue a denial, they had the best opportunity to appeal and win. i will always be a patient advocate first, as well as for those who provide the care and i always hated to see patients/hospitals be denied, because 'criteria' wasn't always clear.
i've been at my present job at one of the largest hospitals in the texas medical center since 2001. i am the only medical appeals nurse for our 900+ bed hospital. when i was hired in 2001, i replaced 2 contract employees, (rn's) who simply appealed everything without even reviewing the record. they just sent the medical record along with (identical) form letters to all the different payors. i was able to bring this dept from a 6% overturn rate to an 87% overturn rate by my 2nd year. the first year was spent recovering from the horrendous flooding our hospital suffered from tropical storm allison. but by year 2, i had the appeals component of our case mgt dept. "in the black". in 2009, my overturn rate was 95%, and was over $6 million dollars.
i've since developed for the um/cm nurses who are on the units interqual 'cheat sheets' re: inpt vs obs, admit criteria, criteria form sheets to send to payors, etc. i've also used 'example cases' in the training of these cm/um's to test their basic skills in both cm/um. all of these cheat sheets, forms and examples, have been utilized in training any of our new cm/um's, as well as refreshers when the criteria changes, or we have a um trained nurse, go into the cm portion of the job. i've just begun developing the same ‘cheat sheets’ for milliman.
i only say all the above, because yes, you can be an lvn and also be an integral part of the case mgt team. in our dept. of 95+ case mngrs. and social workers, we have 4 lvn's. myself, one is the hospital precert nurse, another provides retro reviews/precerts to payors when a pt has already been dc'd. the last lvn works with our medicaid/medicare denials and other issues. she also 'floats' to the units to assist w/um duties when the units are short staffed. all 4 of us are crossed trained in at least 2 or 3 of the other's jobs, so we can 'cover' when one or more of us is out. mine is the only position that is not crossed trained to anyone else.
i love my job immensely. i enjoy ‘winning’ over big insurance and it’s always a high when i can take their ‘iron clad’ denial and get it overturned. it’s been a wonderful experience and i fully intend to be here until i retire or they kick me out!