Need advice, utilization review nurses!

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    Okay, my current situation is that I have been a BSN certified psych nurse for the past 16 years and am willing to do anything to get away from the floor. In particular would like to get a ut review job with insurance company. I have read prior posts but did not really get much in terms of how to transitioning from my current position to utilization review nurse. I have several questions that hopefully someone can help me with, I am desperate!
    1. Being that my only experience is in psych, i would assume that would limit my options to strictly psych ut review? I do have 6 months med/surg experience and have worked with medical patients before, would this be considered?
    2. Would you recommend taking the online case management courses that I have been seeing, like mckesson? or would this be a waste of time any money b/c of my experience.
    3. Are insurance companies still willing to train nurses? I read prior posts that they used to, not sure if they are still training?
    4. What other options in terms of education aside from case managment would work, risk mgmt? hospital administration?

    I am leary of talking with manager about interest in ut review as I just was hired recently into my current position.

    Any advice, comments, or help will be greatly appreciated.

    Thank You!
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  3. 6 Comments so far...

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    Your best bet is to call your local HMO(s) and ask to speak to the disease management nurses in the psych section. There are other ways to use your psych expertise in ways besides UR. They will appreciate your BSN and your long psych experience and may be very happy to train you in their department. I'd avoid McKesson for now-- if the company uses their criteria, they'll train you.

    However, there are also UR people at that HMO company. There are also free-standing UR providers; call and speak to some of their nurses, too, and see if that appeals to you.

    You could also think about getting your psych NP certification and that would open a lot of interesting doors for you while getting you off the floor.
    jjb1 likes this.
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    Grn Tea- Thanks for your response, this was very helpfull, I will try and call some of the HMO places, I am not too familiar with disease management, although I assume its similar to Case Mgmnt. I have thought about NP certification, but not sure I am there yet in terms of the time it will take to obtain. If you or any others have any other advice for me I am always listening! Thanks Again!
  6. 1
    Chronic Disease Managers are Case Managers too. They usually specialize in a particular (or a set of particular) disease processes. Their ultimate goal is to reduce the admission rate of patient's that are at high risk of multiple admissions into an acute care or an acute psych setting. With your background and certs, jjb1, you could be a Case Manager (Chronic Disease Manager) of psych patients. If you do not mind working with patients directly in an office setting, you will work to reduce their risk of being readmitted to a psych facility.

    Hospitals apart of HMOs that have acute care psych facilities+outpatient facilities as well as organizations with outpatient psych services, all have a great need for a nurse like you! I doubt you will have a hard time landing a job even if you are new to being a CM because they will be happy to train you. Good luck!
    jjb1 likes this.
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    Thank You MBARNBSN, this does allow for another option, I have been looking around and intend to call several places that I like. I guess I am still a little apprehensive due to my lack of Case Management experience, but I think I will give it a go and see what happens. I do have another question that you or someone else may have the answer to, is it possible for someone with strictly psych experience and limited med/surg experience (6 mos) to transition eventually from behavioral health or psych c. magmt or ut review to another medical related area of c. mgmt or ut review? I spoke w/ someone and they had mentioned that does happen at times, and they will train you in a specific area of need, just not certain if this is a frequent occurrance? Thanks for all your help!
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    I work for one of the smaller national insurance companies as a Concurrent Review Coordinator (UR), my job prior to this was in an ICU. I had no prior insurance experience but I did have a lot of varying outpatient experience in quality, case management, and insurance authorizations from the clinical side.
    At my company, we actually outsource our mental health case management cases to a company called MHNet that uses nurses as case managers for mental health patients that we refer. So, your psych experience may lead you to a great niche! Also, I have always thought that psych nurses are sort of med-surg nurses too because psych patients have other co-morbities and diagnoses that still have to be tended to even when in psychiatric facilities or programs. You just have to examine your job and draw out the diversity of nursing skills that you practiced...it's there, you just have to examine it and highlight it when presenting yourselves to companies. Also, keep in mind that as a UR or CM nurse, you may be hired specifically because you DO have psych experience and they don't have any other nurses with that background. In my office, we know certain nurses have backgrounds in ICU, or ER, or OB, and we utilize their expertise with the understanding that nursing is broad and we all have something unique to offer.
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    Thank you all very much for your replies, this information has been very helpful. It feels good knowing that I am headed in the right direction and that this is something I can accomplish within the coming years. I will take this advice and use wisely!


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