Any Nurses who work in the insurance field? Talk to me, Please

  1. Hello, I have been an RN for 5years now, I know that isn't really long enough to feel "burnt out" compaired to most of you guys. But beieve me, I am. I haved worked steady, OT and all for all of the 5 years. I've been in Geriatrics, Med-Surg, ER and presently I'm working in Critical Care. I am one of those "Anal Retentive" Nurses, that I feel has now-a-days become a GOOD quality to have. I think it is the understaffing and low pay raises that is my biggest c/o. NOW to the question that I need an expert opinion on, I think I'm interested in trying a completely new job. The one that seems to be the most appealing are the nurses who work in the Insurance Offices. I don't even know what exactly the position is called. I would love it if someone in this particular job would take the time to explain the actual job description, pay, hours, benefits, etc. Also I would like to know more about being a Leagl Nurse Consultant. Anyone know about it from experience? I've checked into the education for it, but am unsure of the profitableness. Thank you so much in advance, can't wait for your replys! CARLY
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  2. 9 Comments

  3. by   Mijourney
    Hi Carly,
    Many nurses who apply for insurance jobs have only had one to two years of experience at the time they applied. So don't feel bad about being a five year nurse. Your years of experience would be enough for most insurers. Your post indicates you have multi area hospital experience which insurance companies look for. You also have that all- important "anal" quality that may help you move through the ranks if you find insurance is your niche.
    The size of the insurance company you work for and the number of subscribers will determine how hard you work. I worked for a pretty good size insurer a while back, and it was rather hectic for me. I worked in what is known as preadmission certification. This is the area that many nurses are hired into initially. It also may be called utilization management as in the hospital. This area will determine if you are cut out for and stay in insurance or not. You will make it or break in this area, because there is alot of information that is generated to be reviewed on paper, fax, or electronic forms. Also, you may feel pressured to help control costs that you did not consider when you were at the bedside. That is uncomfortable for some nurses. I got out, because I missed working with the patients, and I was not sure I enjoyed seeing services denied as well as providers lying about patients' conditions. I went into home health, because it put me closer to the patient and the environment that contributes so much to the patient's well-being. In this area, I spend a little more time discussing, instructing, teaching, and supporting.
    Back to insurance. I did find insurance interesting, however. I got to look at health and medical care from another perspective. I realized after working in insurance, that the insurance company is not always the bad guy. I think starting salaries are equal or better than in hospitals. I think that if you work for a large insurer, your opportunities are wider, and your benefits may be better than the hospital. Also, it's nice to be able to work that 8-4 or 9-5 with no weekends or holidays and not have to take any work home with you unless you want to. I think if you really want to get into utilization management, which includes hospital, insurance company, or some other setting, now is the time, because you seem ready. Perhaps you will find that this area will work for you. Best wishes.
  4. by   Alizza RN
    I disagree with the previous RN re: 1-2 years experience in an insurance employer. I am a RN Healthcare consultant dealing with case mgt. UR, clinical review/medical audit, disease management, coding and reimbursement, government contracts in policies and medicare issues all of whom and allowed me to travel and deal with nurses and other HC prof all over the country - hospitals and all types of payors. UM is only one of the options working in an MCO - managed care org. There are other opportunities - case managemnt, quality and risk mgt, HEDIS and performance measure jobs, clinical and bill audit review, compliance and many others. Your 5 year acute care experience is a good start. You need to take few courses depending on your interest - UM/CM, learn coding and reimbursement methodologies, understand the intricies of Medicare as a payor and deliverer of care. membership to professional org of these specialties are also helpful. Pay is equitable now with all the RN shortage around. Most of them require BSN. PC skills is a must and writing summaries and analytical talents in graphs and tables is a plus. Any more questions - email me. Good Luck......
  5. by   Mijourney
    Originally posted by Alizza RN:
    I disagree with the previous RN re: 1-2 years experience in an insurance employer. I am a RN Healthcare consultant dealing with case mgt. UR, clinical review/medical audit, disease management, coding and reimbursement, government contracts in policies and medicare issues all of whom and allowed me to travel and deal with nurses and other HC prof all over the country - hospitals and all types of payors. UM is only one of the options working in an MCO - managed care org. There are other opportunities - case managemnt, quality and risk mgt, HEDIS and performance measure jobs, clinical and bill audit review, compliance and many others. Your 5 year acute care experience is a good start. You need to take few courses depending on your interest - UM/CM, learn coding and reimbursement methodologies, understand the intricies of Medicare as a payor and deliverer of care. membership to professional org of these specialties are also helpful. Pay is equitable now with all the RN shortage around. Most of them require BSN. PC skills is a must and writing summaries and analytical talents in graphs and tables is a plus. Any more questions - email me. Good Luck......
    \

    Hi Alizza,
    Thanks for the feedback. I agree with your assessment about insurance opportunities. I do know of nurses with 1-2 years of nursing that applied for insurance work in an effort to find something different from bedside nursing. It does not mean they got hired, however. I was started in UM preadmission certification, because there was a big need in that area, and I did not have some of the background that you suggested taking courses in. Many of my co-workers at the time found that as they moved into other areas of insurance such as quality improvement or case management, that the PAC experience proved very useful. It gave them a good foundation as med-surg would in a hospital setting. As you write, it does not mean the person has to start in PAC, though.

  6. by   Alizza RN
    Nurses would also do great as Medicare compliance officers or specialists. This would not only be an opportunity to work in an HMO environment, but to all health care org. as well. Compliance is so BIG in the eyes of the government that it is a requirement to have compliance programs in all entities. Nurses fit perfectly in this area - the clinical combination, the versatility and the ability to detect fraud and abuse is not only a talent for lawyers but for nurses too. Learn Medicare from head to toe and that should get you in.
  7. by   Carly
    Hi Mijourney & Alizza RN! Thanks so much for the time you gave me with your replys. It really helped. I was kinda hoping that I could enter the field without any more CLASSES. But I guess I just can't have my cake and eat it too, huh? I would like to start learning more about Medicare, how would I go about that? And when I am looking in the classifieds what will be the job title names I'm looking for? Thanks again! CARLY
  8. by   Alizza RN
    Depends on what you are doing now... are you doing anything that is related to healthcare policies, case and disease management, medical necessity issues, understanding of Medicare reimbursment methodologies, knowledge of ICD 9 CM, HCPCS, APCs, DRGs, Risk adjustment models, MDS, RUGs, bill review and fraud and abuse/compliance issues, encounter data, RBRVS, quality intiatives related to medicare, stats and Medicare cost... too many to mention. If you are in any of these areas - you are on the track. I find that many of our colleagues in our nursing profession do not want to have anything to do with these and nothing is wrong with that. But for those that would like to be involved in areas more than acute and subacute care nursing, this is a good chance to be involved --- because one day we all are going to be beneficiaries of Medicare or Medicaid.
  9. by   Mijourney
    Originally posted by Carly:
    Hi Mijourney & Alizza RN! Thanks so much for the time you gave me with your replys. It really helped. I was kinda hoping that I could enter the field without any more CLASSES. But I guess I just can't have my cake and eat it too, huh? I would like to start learning more about Medicare, how would I go about that? And when I am looking in the classifieds what will be the job title names I'm looking for? Thanks again! CARLY
    Hi again Carly,
    Take note of Alizza's reply. Also, it would be good if you knew someone working in insurance. The reason for this is that many nurses with more clinical and administrative background then perhaps you have are getting hired into insurance. Therefore, it can be quite competitive, not impossible, to get in many of the specialty areas that Alizza is suggesting without the courses she has suggested. As far as my experience with Medicare is concerned, I have an acquaintance that works as a nurse consultant in Medicare reviewing or auditing charts retrospectively. In addition, I know of Medicare nurse consultants that do concurrent reviews in the office and on site as well. The on site obviously would entail some travel. There was no additional course work required for these positions and no BSN was required as with PAC. You need to demonstrate knowledge of Medicare and anything surrounding Medicare and a willingless to learn more. If you're really interested in beginning your learning about Medicare, you might want to check out the Health Care Financing Administration's website (HCFA) as well as the Department of Health and Human Services website (DHHS) of which HCFA is under. You can also check out the website for the National Commission for Quality Assurance (NCQA) which accredits managed care organizations (MCO)to get an idea about accreditation and MCOs. I'm sure Alizza or someone else will be able to provide more details and information. I'm still working on how to do attachments on this type of forum. Best wishes.

  10. by   Alizza RN
    Email me if you need to know more...
    Alizzarn@aol.com
  11. by   Alizza RN
    http://www.ltuextension.com/

    This site have programs to learn Medicare Regulations Compliance and Payment - an intro to learning Medicare.

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