Interview next week....UM/UR

No, I do not think that this is a typical utilization management CM position. I work as a UR nurse (have done so for quite some time) and I do not deal with complaints per se even when I issue denials of coverage. I could totally be wrong in your case, but as a UR nurse where I have worked I have pointed patients and families to another department (usually back to his/her insurance carrier) to complain or grieve unless the issue had to do with services within the hospital I worked... then I pointed the patient to our compliance department, which handles complaints/grievances and appeals. Thus, my guess is that your position is more along the lines of Customer/Member services or Compliance.

All insurance companies have a division dedicated benefits and it incorporates a place where people can complain and they usually staff it with nurses and non-nurses to address medical expenses and/or medical service delivery benefits and accept grievances and appeals. Plus, all Health Care delivering agencies have a department dedicated to Compliance and that department will also deal with grievances and appeals.

Unfortunately, at this time the only other forum that is close to compliance and member services issues other than this forum is the QA forum: https://allnurses.com/quality-improvement/.

Good luck.

Thank you for your response. I will find out more info during the interview.

One of the preferred qualifications listed UM/UR experience and being familiar with Medicare MS-DRGs/PPS. I won't list the entire listing but this was also bulleted point.

Provide a positive financial impact to the institution through interaction with physicians, nursing staff, other patient care givers, and coding professionals to ensure that medical record documentation accurately reflects the level of services rendered to patients and the clinical information utilized in profiling and reporting outcomes is complete.

One of the preferred qualifications listed UM/UR experience and being familiar with Medicare MS-DRGs/PPS.

Provide a positive financial impact to the institution through interaction with physicians, nursing staff, other patient care givers, and coding professionals to ensure that medical record documentation accurately reflects the level of services rendered to patients and the clinical information utilized in profiling and reporting outcomes is complete.

Although above can easily be UR/UM, compliance officers must know and be familiar with UR/UM, DRGs and Medicare regs, proper documentation, ICD 9 and/or 10 codes and appropriate levels of services too. On the other hand, if the title of the department is Utilization Management, Resource Management, Case Management, Continuity of Care, etc. then the position is definitely UR/UM. :)

What is the name of the department that posted the position? What title is given to the nurse they plan to hire?

Sounds like you will be reviewing documentation to justify the DRGs and other codes being billed. Hospital I previously worked at had a similar position. These were also the people who would leave notes for the providers in the charts asking them to specify type of heart failure, why they may not be on appropriate medications for a certain diagnosis, etc

The title is Case Manager RN and department - Compliant Documentation Management.

I will look through the QI section as well.

AnnaN5

At a previous employer, we had the position you described and they were called Clinical Documentation Specialists or something similar.

The title is Case Manager RN and department - Compliant Documentation Management.

It's Compliance; I will be very surprised if it is not. :) Compliance departments have "case managers" too, but not the same as the CMs that are on this forum. Similarly Hospice has "case managers" as well, but they are not like us either. Also, I too worked for a hospital that has "Clinical Documentation Specialist" as well as "Appeals Specialist"; both are nursing positions and both work under the Compliance department umbrella. Thus, until the powers-that-be decide to make a Compliance Nursing forum QI/QA and some of the resources in this forum will be of some help. :)

All of it will be new for me so I will be sure to ask a lot of questions. Maybe they will let me shadow someone for a half day since I'd be an internal transfer.

My interview went well. The position is pretty much the same as a clinical documentation specialist. I'm shadowing someone next week and then we go from there.

My interview went well. The position is pretty much the same as a clinical documentation specialist. I'm shadowing someone next week and then we go from there.

Congrats! :) I made a request for a Compliance Nursing forum. I am thinking it should also include Regulatory Agency Nurses since both are focused on compliance measures. My request is pending. :)

I hope you get your new job. I am a UR nurse, however I work very close every day with our Clinical Documentation Specialist. Her degree is in HIM, so it is nice to work with her because she looks at a chart from one perspective, and I look from another. It has helped me to learn more about DRGs, and coding.

Well I did end up getting the job and start next month. My title is Case Manager RN lol. The other traditional case managers are also managed by the same director.

Well I did end up getting the job and start next month. My title is Case Manager RN lol. The other traditional case managers are also managed by the same director.

Are there other RNs like you doing your job? If not, when your department is short staffed you will probably be taken from your normal duties and responsibilities to cover the traditional case managers. Thus, be sure to get the training to do that job as well while on orientation.