Administrator trying to Override RN Recommendation

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Specializes in Case Management.

I work for a very specialized insurance who only recently was mandated to bring in RNs. My immediate supervisor is a LCSW. I had assessed a client and found him to not be in need of acute RN CM. I recommended quarterly contact from a Care Coordinator and documented everywhere, "member knows how to reach out for assistance. Member has demonstrated competence in managing medical regimen. Member in agreement with no longer requiring acute care management." I'm only there 7 mos and have clued in to the fact they really don't know how nurses work and who nurses take directive from. After I submitted my recommendation, an Administrative Aide II told me it was "too soon" to release the patient from RN CM. Honestly, I held my tongue. She wants to "talk about it" on Monday. Hx: pt underwent surgery in August and received about 3 weeks PT rehab at home. It's November. He's young, out and about. I'm tempted to say, " You think it's too soon based on what?" Any recommendations on how to inform these inexperienced Admin Assts they have no place questioning my clinical assessment/POC?

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Specializes in NICU/Mother-Baby/Peds/Mgmt.

Good luck!  With Google Medical School everyone thinks they're an expert.  All I can say it's going to take time. And I would ask that question, but in a really nice tone of voice, not snarky or condescending.  If you can manage that... I'm not sure I could! ?

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Specializes in school nurse.

Probably a revenue thing? (Fewer services, fewer billable hours.) Or given that it's internal, fewer demonstrable service hours for the department?

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If the  administrative assistant can override your decision, you must ask what is the benefit to the company? Keeping him in CM is all about revenue.

As you have only been there seven months, take more time to observe the process. You are NOT there for the members, you are there for the company.

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Specializes in Case Management.

It's really such a specialized insurance created only for this very special group of american heros... I've said too much. It's supposed to be all about them. I think I'm very bothered by a non-clinical individual even thinking they have the authority to second guess my nursing judgment. If I thought my client needed continued acute care managment... I'd keep him. RNs are a new addition to this organization. They don't know what to make of us. We started with 4, now we're down to 2. My caseload is like 90...some have to be downgraded to be able to manage those who need it. Really, RNs are the only ones qualified to assess, right? Never, ever had Adnin question my judgment in 20+ years.

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I think any team member should have the ability to have input to a decision, but an unlicensed person, or a person working outside their scope, shouldn't be able to override it.  I remember working in Corrections, and sometimes the officers had insight to a situation that was valuable.  They spent more time with the patients and understood when something was not normal.  That said, when a high school grad with no training argued with me after I had assessed the patient, and had no objective data to add.....yeah, that pissed me off. 

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Specializes in Case Management.

I struggle with is it my ego, or does this person need to know they got no business questioning an RN in this setting. Probably both.

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On 10/25/2020 at 5:03 PM, Babsuptown said:

RNs are a new addition to this organization. They don't know what to make of us. We started with 4, now we're down to 2. My caseload is like 90...some have to be downgraded to be able to manage those who need it. Really, RNs are the only ones qualified to assess, right? Never, ever had Adnin question my judgment in 20+ years.

I think you need to do some educating.  Time to patiently explain what you're there for. Explain the concept of triage. As the RN, your job is to manage the more difficult cases that cannot be overseen by someone without a clinical background.  If you spend your time on the ones who don't meet RN criteria, then you don't have the time to give the medically complex patients the attention their case deserves.  

What you write here reminds me of some of the NPs who join private practice, only to find the MDs have no idea what do to with them and keep giving them RN duties instead of letting them see patients. So they're paying NP salary for RN tasks instead of letting the NP bring in revenue. Some of those doctors are turf-protecting jerks, but others genuinely do not understand scope of practice.

Does this Admin Aide have veto power?  If not, who does?  You state you make the recommendation, but who makes the decision? You may need to go up the ladder.

 

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Specializes in Travel, Home Health, Med-Surg.

 

 

 

On 10/28/2020 at 5:00 AM, Babsuptown said:

I struggle with is it my ego, or does this person need to know they got no business questioning an RN in this

I would be interested in what your job description states. This situation could pose a legal and professional problem for you, the ego thing aside!

Who has the final say so. If it is admin and that is clearly documented than may not be a problem for you. If they are going to pressure you to do something against your professional judgement could be a very large problem for you. Probably why they have already lost to nurses?!

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I feel the place mainly wants your license and not so much your expertise. They have tge assistants for that. What a mess.

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Specializes in Case Management.

Well, now that you say it like that...simple and profound. I thought they probably just didn't know any better. I'm so gullible! Thank you!

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Specializes in Case Management.
On 10/29/2020 at 4:57 PM, turtlesRcool said:

 

Does this Admin Aide have veto power?  If not, who does?  You state you make the recommendation, but who makes the decision? You may need to go up the ladder.

 

She is ambitious. And my LCSW manager emboldened her by having her distribute those who are downgraded to the other care coordinators. I think she just thought she could direct an RN because the manager seems to like her. I spoke loud enough, in a nice enough voice, and made my determination known.

 

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