CM for AmeriChoice or Hosp? DIfferences?

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Hi,

I was wondering if I could get some clarification on the CM duties for and insurance Co. like AmeriChoice and the CM duties at a Hosp.

I have 10 yrs as coord of care for a home care agency, ICU, Med surg, STD and Concurrent review. I've been a nurse for 16 yrs.

It seems the title CM can mean different things to different organizations! My position as a concurrent review RN was also called case management. Can anyone help me understand the different CM positions?

Any enlightenment would be appreciated.

Thanks

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You could go on their web site unitedhealthgroup.com and look at their job description for different CM positions that are posted. Hope that helps.

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Thanks, I have. I was just looking for some feedback as to the differences in CM positions. Relatively new to CM except for my homecare experience. I would imagine working for a hospital or an insurance company would entail different skill sets and I was just wondering if anyone has worked either and if they could elaborate on their experiences.

Thanks, again!

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Specializes in Critical Care, Insurance Case Management.

I have done both. I worked for insurance as a case manager for worker's comp and no fault auto - those cases are long termers, meaning they are the medically complex and usually have psych components related to long term disability. It can be hard to move those folks forward and make choices, none of which are as good as they thought they had it before they got hurt. You get to know them well, but it is slow going. Often there is vocational rehabilitation and retraining planning.

Inpatient is completely different. You get a case load every day, usually with 15-20 patients or more, about 30% can be new every day give or take. Every day you field pages, work on discharge planning, handle social work issues, and in my case, include insurance reviews for which you don't really have time to deal with. Much more stress, more variety, faster paced. Sometimes you feel you are drive by case managers, because you don't have time to teach or listen much. I am supposed to see every patient within 24 hours of admission, but in reality I maybe see 5 out of 18 or 20. Some days you see only 1 or 2. Some days you can see 8 if you have no insurance reviews and no one needs anything. I would be much happier if I didn't have to deal with the insurance stuff - that is a job in itself and has no place in the case manager job, in my opinion.

It all depends on which pace is right for you. I like seeing patients and family, and helping with discharge planning tranfers; I don't like feeling like if you spend more than 15 minutes with a patient, you will get behind or get paged.

Insurance work means complications like chronic pain, disability lawyers, entitlement attitudes, and rare successful return to productive work, but it does allow a closer working relationship with patient and families.

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Thank you for sharing your experiences.

I have been searching for a case management position that will allow me to teach and advocate for patients without direct patient care (and all that traveling) as I did in home care. I feel that's my forte.

Any ideas?

Thanks for all your advice and insights.

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Specializes in Critical Care, Insurance Case Management.

I am thinking the best way to do that is to become a certified diabetic educator. I am leaning that way myself, or I was until I found out my old job in mental health is available full time. I like to specialize in something, and inpt cm doesn't allow the time to specialize or teach, even though they say you can. 25% of adults in this country are diabetic, and with the focus on prevention - diabetic teaching and self management is essential

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Yes, I was looking into CPHQ (Certified Professional Healthcare Quality certification). Disease management seems to be the thrust of healthcare reform and I think it would afford me the opportunity to still impact my patient's lives.

The problem is, when I look at case manager postings, they mean different things to different companies. Any key words that companies use to help me narrow my search along the career lines I'm referring to?

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Specializes in Home Care/Home Infusion.

Case Management does mean different duties to different companies. A true case manager is defined by the Case Management Society. There is a certification you can take. It is very involved. But, there are very specific guidelines.

Hope this helps!!

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Thanks.

I do want to get my CCM and have looked into the requirements. I need clarification on whether I need to work as a CM before I can take the courses, or, if my extensive Home Care background meets the requirement.

Any input would be appreciated.

I did take some sample questions (for what its worth), and aced them. I've reached out to CCMC for more info, but any additional tips from you fine folks is always welcome.

Thanks.

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Specializes in Case Managemnt, Utilization Review.

I cracked up at the adlockwood post, how true is that - in hospital you do it all, utilization review and discharge planning , insurance medication authorization, for insurance company, you take calls all day from the hospital folks doing case mangement setting up home care auths and doing your assisgned hospital caseloads, which change daily as patients come and go out of the hospital- then you need to do daily reports and update census info

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