New job as a Case Manager/Quality Assurance Reviewer

Specialties Case Management

Published

Hello all!

So I have finally landed the nursing position that I think I can excel in. Honestly, floor nursing was not for me, although I did enjoy the direct patient interaction and gained a lot of valuable knowledge and skills, the work was too technical. I am one who likes to research and write a lot.

Likewise, my search for a position like this ended today! I was offered a position as a case manager/quality assurance RN for a non-profit organization that serves low income individuals and families, including those who are uninsured.

I am really excited about this new opportunity and hope that it is a place where I will love to work at! Just a few questions though for those who are experienced nurse case managers and who are currently on the process of learning in their new job.

What is the best way to prepare for this position?

I know that I have to be knowledgeable about health insurance, Medicaid, Medicare, etc. what kind of information do you think I need to research on?

Also, my manager told me that I would also be responsible in writing policies and procedures for the organization and responsible for reviewing documentation. Honestly, I am kind of nervous. I am confident in my ability to write, but what resources can I use to prepare myself for a task like this?

Thank you all!

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

Read the CMS government website and the resources listed on the Case Management Society of America's website (books, magazines, etc). Those can go a long way to help you understand the rules related to and regarding this specialty and Medicare and Medicaid. By the way, no offense, but since you do not have a background I do not know why you will be writing policies.

With that said, I think your job is either one that no one with experience wants or your new bosses were just blowing smoke up your bottom in the interview. In fact, I am almost positive it is either one or the other if it is a true Case Management position.

On the other hand, maybe the position is either QA or CM? If it is actually only quality assurance, I can see you gathering data, analyzing data, and making recommendations towards policy adjustments. However, if it is only a case management position, I think you will input data to be collected and analyzed later, but you will be too busy doing a million other things given that the Medicare and Medicaid population is very sick and in need of much of your time, to write policies. This is why normally RN Medicare and Medicaid positions are not both QA and CM.

In any case, congrats on the opportunity to get away from bedside nursing! Hopefully you will enjoy it and be doing what they told you during your interview! Unfortunatley, my experience is that interviewers can fudge the truth (or wish for something aloud, they cannot deliver) when attempting to fill hard-to-fill positions. Good luck!

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That sounds more like a QA job to me for sure not actual CM. In our organization all of our QA reviewers that review the CM documentation are RNs and most are also CCMs. I hope that you have a tough skin, because you will need it in this position...... :-)

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Know your employers policies and business rules inside and out.

Once you get a handle on that.... it'll all fall into place.

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Well, a case manager has to start somewhere and most have been "on the job training." I am considered a subject matter expert in CM/DM/UM. The first advise I have for you is to become a member of CMSA (Case Management Society of America) and absorb the definition of CM, the code of conduct, and especially the standards of practice. If you are a member, there is a plethora of tools and resources you will have access to that will prove to be valuable as you grow in this specialty. There is also a totally online MSN program at American Sentinel University that focuses on Case Management. Your goal in the next two years should be to work toward a CCM (certified case manager) that CCMC provides. Make sure you know the criteria for sitting for the exam.

Dawn

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@ MBARNBSNYou seem very knowledgable at what you do. I'm a nurse student and I truly believe that case management is what I want to do as a specialty besides pediatrics. As a nurse student I would like to get familiar with CM language and want to read books, practice test, etc on my down time in between school. Do you know of any great sites? Thanks :)

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tasha92337 this site is without a doubt ( IMHO) THE place for information about case management. You can't get certified until you have experience (Catch 22) so book learnin' won't do you a whole lot of good at this point in your training. I would say the best initial experience you can get for CM is as a visiting nurse.
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d'cm

Thanks. The reason why I ask is because my mom is a RN and she works at home doing case management and I want to start getting my feet wet any way possible. If I wanted to volunteer at my current rehab hospital job to help with auditing or discharge planning, can this help enhance my interest in learning CM?

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Specializes in ED, ICU, MS/MT, PCU, CM, House Sup, Frontline mgr.
@ MBARNBSNYou seem very knowledgable at what you do. I'm a nurse student and I truly believe that case management is what I want to do as a specialty besides pediatrics. As a nurse student I would like to get familiar with CM language and want to read books, practice test, etc on my down time in between school. Do you know of any great sites? Thanks :)

Case Management Society of America's website (Case Management Society of America > Home) and the book "Nursing Case Management From Essentials To Advanced Practice Applications" by Cohen and Cesta, which is a text book in some nursing programs, can be helpful. The website provides a lot of definitions and gives an overview of case management. You can also join your local chapter as a student (Case Management Society of America > Individual). Doing so may help you learn more, land an internship in Case Management, and participate in case management policies etc. prior to graduating nursing school. Good luck!

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Awesome! Thank you :)

I would LOVE to land an internship in CM

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