Anyone worked for insurance co in claims?

[Blouis, APRN]

I am close to my wits end with floor nursing and considering a transition into somthing else with my degree. I applied for a position with an insurance company as a medical reviewer. I am assuming I would be reviewing claim forms and sending out letters of approval or denial. Not really familiar with this area. Does anyone have any experience working in this field? What are the hours? (she told me its flexible working 4 or 5 days a week) What are the working conditions? Am I expected to approve procedures using their guidelines? If you worked there, why did you leave and what did you like about the job?

Any help would be appreciated

[linearthinker, DNP, RN]

I would have a huge ethical problem with working for an insurance company. I wouldn't do it unless my children were starving and losing weight.

[Blouis, APRN]

I have a huge heart Line...great point. Not sure if I can actually say no to people I know needs a livesaving procedure. I am unclear if I would be making that decisions or just processing paperwork.

[linearthinker, DNP, RN]

I don't know, i just know I could never be part of the machine.

[itsmejuli]

I worked for one of the largest medical insurance companies adjusting medical claims. I was not a nurse then and didn't do medical reviews.

I hated my job, I sat behind a computer and did nothing but review contracts and benefits and pay claims. I had to deal with both billing providers and sometimes the insured while paying out claims worth hundreds of thousands of dollars. I had no interaction with people most of the time since I was a telecommuter and very little job satisfaction.

Your job in medical review might be a bit more interesting. If you're on the claim side you'll probably be reviewing appeals for claims that were denied/underpaid/overpaid for some reason or other. Often times this is the fault of the billing provider who billed incorrectly. Sometimes its the fault of the insured for not following plan benefit guidelines.

IMHO, its a pain in the butt job with little job satisfaction and too much stress caused by corporate b.s. You haven't seen corporate b.s. until you work for an insurance company.

If you want a desk job with an insurance company go for triage where the nurses review prior to procedures. But then again, you're going to be stuck on a telephone and computer and will have to meet production and quality goals.

Been there, done that, never again.

[Blouis, APRN]

thank you for the insight Juli..gives me some info on what may be expected for this job. I currently work at 2 hospitals in the float pool and have been faced with low patient census and callouts quiet a bit. I love flexibility of working PRN but 12 hours and hospital burnout and thought this would be a nice change

[TDCHIM]

Given that you're an RN, you might consider the role of a clinical documentation specialist if you're looking for a change. Here's a link to a description: http://www.psqh.com/online-articles/231-the-clinical-documentation-specialist-a-key-member-of-quality-and-patient-safety-teams.html It's basically a job done by an RN with additional training and expertise in documentation/coding and/or by a RHIA with considerable clinical knowledge.

If you're interested, try the website for the Association for Clinical Documentation Improvement Specialists: http://www.hcpro.com/acdis/ As I understand it, most of the time you would be working with a facility's medical/nursing staff (along with people from HIM and billing) to make sure clinicians were documenting in a way that allowed their documentation to be used properly and effectively by those doing the coding and eventually the billing. So a role as a CDS wouldn't be like working for an insurance company, where you might well be stuck looking for ways to say no to claims.

[nurse0520]

I used to work for a major health insurance company. it sucks i did not know what i was getting myself into. i thought i would be helping people. NOT!!! i was bullied by the catty women working there because i was not part of their clique. they wanted us to find a way to deny a claim for the most part, especially chiropractor and physical therapy. if you do not have to, dont. though i would have never worked there if the college i went to for my nursing would not have given me a hard time for the operation i had done and i would have gone earlier for nursing

[upstatenygirl, LPN]

i used to work for a major health insurance company. it sucks i did not know what i was getting myself into. i thought i would be helping people. not!!! i was bullied by the catty women working there because i was not part of their clique. they wanted us to find a way to deny a claim for the most part, especially chiropractor and physical therapy. if you do not have to, dont. though i would have never worked there if the college i went to for my nursing would not have given me a hard time for the operation i had done and i would have gone earlier for nursing

all of these comments are helpful to me as i am finishing up my degree in medical billing and coding. throughout the program i did find the insurance aspect unapealling. i could work at a facility as a coder or work for an insurance company. i think i am going to get a b.s. in human services. i was checking out the many possibilities on the cdc website. thanks for the tips! :)