Confused non-clinician in need of RN educator! Case Mgt vs. UM vs. UR?

[aliehogan]

I'm a very confused RN Recruiter who is lost in the sea of grey that is Case Management / Utilization Review / Utilization Management. I need to understand your world better to be able to find the right candidate and FAST! The hiring manager wants someone who has "Utilization Management" experience, specifically in writing appeals / handling denials. She wants someone with hopsital based experience ... says payor based experience is valuable but must also have hospital experience. Add to that the need for someone who has experience as a leader / manager and I'm stumped!

I've been combing through resumes & leads for weeks and honestly my head hurts from trying to figure out how to get to candidates with that mix of background. Some Case Managers have UM experience, some don't. There seems to be no end to the different titles for the Nurses who do UM or UR. Anyone out there willing to give me a beginners class on your specialty? Promise I won't try to recruit you!!

[d'cm]

I'll give it a shot.

I have never seen a position called a "UM" nurse. Utilization is managed by proactive discharge planning, identifying "avoidable days" and utilization review ( identifying medically necessary / unnecessary admissions) all of which is usually incorporated in the title case manager. Some facilities split these tasks up into different titles i.e UR RN and Case Manager.

Appeals and Denials utilizes UR skills much more than CM / dc planner skills. If you are hiring an appeals manager (without supervisory duties) they will undoubtably have manager type duties, e.g be able to produce and present relevant information in committee meetings, and possibly negotiate payment rates from payors.

I have done appeals for hospitals and payors and had no management experience and did just fine. The essential skills are strong clinical knowledge and analytical ability. This does not necessarily mean a nurse, doctors who couldn't get licensed are also excellent.