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Is managed Medicaid the worst of CM?

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Joe NightingMale has 4 years experience as a BSN, RN and specializes in Med surg, cardiac, case management.

33,866 Profile Views; 469 Posts

I'm starting to wonder. I work for a major insurance company that manages a state Medicaid program. It's my first CM job, and I have to say, I hope the whole field isn't like this.

Our members are hard to find, the majority of them have mental illness, oftentimes very serious. We only have telephonic contact, which is good as I've been shouted at and cursed and even had to call the police when an deranged member threatened to come to the office and kill me. And did I mention...I have no mental health experience? I'm all med-surg and cardiac ICU.

Doctors seem to dislike us, finding specialists for our members is next to impossible, as is home health, and I can never seem to get accurate information about who our in-network providers are.

Things are highly disorganized, with heavy turnover and frequent changes to policies and procedures and poor interdepartmental cooperation.

I never seem to use my nursing skills, mostly what I'm doing is finding doctors for people and helping get medications and medical equipment. And also assisting with getting procedures authorized, that's big. Which is funny because here UM is completely separate from CM. So authorizations shouldn't even involve me.

Really, a social worker assisted by a secretary could do my job. I'm not using my clinical skills at all or my teaching skills all that much.

Is this just the company I work for, or is it just managed Medicaid, or is this kind of thing found everywhere and it's just the luck of the draw depending upon the position?

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QTNurseBSN has 9 years experience.

65 Posts; 2,981 Profile Views

I am a nurse case manager for an outpatient mental health clinic and my position is probably less than 1% nursing and the remaining 99 % is secretarial (phone calls, emails, paperwork, paperwork). You don't have to be a nurse to do my job. I do miss the patient care and patient interaction. Not sure if hospital case management would give me more of that, but the outpatient clinical setting does not. The majority of our clients are Medicaid recipients, which is a primary funding source. I have to get approval from Medicaid for services and do a lot of state reporting data. I dislike strongly working Monday-Friday, but I like my autonomy and my weekends and holidays off. This job works well for my family because I also have flexibility, but sometimes I wish this was a three 12s or four 10s kind of job so that I can have more days off during the week. I'm trying to hang in there so I can become a CCM and see where that leads me in the future. I will meet my two year mark April 2014 to qualify for the exam.

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nfahren05 has 18 years experience and specializes in Pediatrics, PICU, CM, DM.

38 Posts; 1,164 Profile Views

Managed Medicaid is one of the most challenging areas of case management, and (due to Medicaid reimbursement,) it's one with the highest ratios of nurse case managers to members. I've done hospital case management, commercial telephonic case management, and (for 6 long months,) a Managed Medicaid program similar to yours. We encountered many of the problems that you have found, e.g. members who were difficult to find, difficult to work with, and had benefits that made it difficult for the physicians to help them. I would have liked to stay longer, but the 400:1 ratio of members to CM made it impossible to get anything done, and created a huge liability risk for us as nurses. I was involved at the start-up of the project in our state, and would hope that things have gotten better by now, but I don't know. Most of the members do need social workers more than they need nurses, but for whatever reason, the company hired more RN's than MSW's. The initial assessments that we had to do for each member did require nursing knowledge and judgment, but after that, a social worker and a clerical person could indeed have helped, assisted by a nurse, only as necessary. As an answer to your question, I would say this this is mostly the fact that you were working with Medicaid, and that most telephonic case management is quite different.

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3 Posts; 761 Profile Views

Sorry for the late response, but I had to comment. I am currently an RN Care coordinator for a company that manages the medical care of complex special needs children on our Medicaid plan. They basically get assigned to our "network" when a physician has referred to us because we offer a clinic and care coordination. It is solely telephonic and currently our ratio's are about average 270 patients: 1 nurse. The caseloads are split by primary diagnosis, ie neuro caseload, endocrine caseload, etc. The job, like you stated above, really involves minimal nursing skill and mostly organization of services, submitting authorizations for meds and DME, answering phone call after phone call from disgruntled patients (parents), and spending a preposterous amount time reassessing their eligibility financially and medically. We all feel that this is a glorified clerical job with a touch of nursing and a touch of social work, as someone said before, it almost feels that a trained clerical person could do this job and just call the nurse or social worker a couple times a day to ask a specific pieces of advice that could really just be Google'd. Also as you said, one of the most difficult parts of this job is the lack of clarity in all aspects, from defining who exactly our provider are from day to day or what exactly we are supposed to do with basically everything that comes in, as things seem to change daily. ALL and I mean ALL of our training was based on the word-of-mouth of other care coordinators. Everyday consists of an anonymous chirp from the cubicles "Does anyone know of a ___ specialist in __ town? ...Wait for someone to yell out "I referred to Dr. XYZ a couple months ago, but I heard he might not be taking the plan anymore. I'm not sure, but I'll drop off this torn up post-it note with his office ph# which may or may not be out of date/inaccurate because I got it from another care coordinator 5 years ago who has since quit." Or most infamously, a flat out "No, there are no providers. They will have to travel at least an hour." Then comes the 5 minute self-talk to prepare for the total frustration you will encounter one you call Mom and tell her, like a blowhorn being set off directly in front of your face. The lines are innately blurry and those who require clear guidelines and precise direction are constantly stressed out and frustrated at this job.

Despite this, I am actually relatively happy with my job. I am by nature very go-with-the-flow and able to work with a lack of direction (actually stifled by rules in general) and to be honest I do not take this job seriously. I take the needs of the kids seriously, but not the total lack of organization of the system. I look at it, shrug my shoulders, and move on fairly quickly. I don't spend much time fighting a system that could never be changed by a single peasant such as myself, nor do feel the desire to. I do what I can in the scope of whats available and I often find it to be a scope I must constantly define and redefine myself. With this, I do feel very autonomous in my job, yet also very connected to my co-workers because we all work together trying to define this undefined system. I am coming to see that although first and foremost, the system sucks, it is a difference in personality that decides whether or not someone can handle this job and whether or not they will be likely to dread Monday mornings. I rarely dread going into work. I sometimes even look forward to it-- to see whats going to happen, what we'll discover, what kind of BS will happen, what kind of weird phone calls I'll get, what I'll learn, etc. Those who come in expecting clarity and direction are constantly fighting a battle that they never win, and therefore they get burned out repetitively, every single day.

Anyways I just wanted to post this to let you know you are not alone! Lack of clarity, glorified "complaint hotline" as we call it, billing representatives, etc all play a much more frequent role than that of an actual registered nurse, and we get paid significantly worse than those in the hospital, BUT it is not the hospital, I get to decorate my cubicle, M-F with all weekends off, salaried, rarely have to see a patient, never have to touch them, I really can ignore calls until I'm READY for them (unless urgent), I am not micro-managed, and there really is a whole lot of comedy in the chaos, if you can see it. Good luck!

Edited by sboet

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Joe NightingMale has 4 years experience as a BSN, RN and specializes in Med surg, cardiac, case management.

469 Posts; 33,866 Profile Views

Thanks everyone for responding.

My opinion of this field has actually shifted quite a bit. Still a lot of chaos, a fair amount of stress, and lots of clerical work and complaints.

But I've come to realize I seem to be quite good at this. I seem to have the talents for this position, in a way I did not with floor nursing. My co-workers and supervisors seem to agree. And I'm feeling more positive towards even the difficult days.

Yes, it is more like social work or psych nursing than medical floor nursing. But I'm finding I'm starting to like the social service aspects. And I'm getting more interested in and more comfortable with the psych aspects.

It will be interesting to see how I feel in a few months...

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3 Posts; 761 Profile Views

Haha Joe NightingMale, I totally agree. It ebbs and flows. Some weeks I want to drop out of existence, other weeks I think I have it pretty good. And I agree, part of the reason I like this job is because I'm good at it. I'm also getting comfortable with my population (peds neuro) and becoming more knowledgeable and (shockingly) INTERESTED! To be honest, I chose nursing for the stability and the general idea to help humanity. Come to realize improving humanity is a different thing than direct interaction with individuals you can't always help, especially with Medicaid. I really should have been an author of philosophy or something, wandering the natioanl parks, thinking all day, but hey I also wanted to have some stability, a family, and to maybe not live in a storage unit for the rest of my life. This job can suck, but my worst day here is better than an average day in the hospital, for me. Anyway, glad you are adjusting :) Wish you well!

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SHGR is a MSN, RN, CNS and specializes in nursing education.

2 Articles; 1,405 Posts; 31,270 Profile Views

I just wanted to say I love you guys. I work in a clinic that takes mostly Medicaid and it is such a treat to have a patients that have Medicaid HMO's vs Straight T19 because there actually are people like you that we can call and get assist from...also more benefits for the members (diabetic shoes, things like that). So thanks for all your hard work and being there on the other end of the line when I need your help!

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Joyful68 has 30+ years experience.

3 Posts; 568 Profile Views

Late to this party, but you are asking a question I asked myself before the program I worked for went away (defunded). Now I work in Medicare and would give my right arm to go back to what you are doing, bad neighborhoods and all. Just to toss those two cents in.....

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