Practicing without a license?

Specialties Case Management

Published

I've been working for a small insurance company for the last two years doing utilization review. When I was hired having 3-5 years of direct patient care experience was a component of the job description, but having an RN license specifically wasn't required. I had an active, unrestricted RN license at the time I was hired, but my job title was only Care Manager.

(The added wrinkle is that I work for a company that is trying to "disrupt" insurance, by playing fast and loose with qualifications and outsourcing pretty much everything, and rebrand as a tech company. The new CEO and other Chief's spent the last 2 1/2 years gutting departments, so that at this juncture most of the P&P's are out of date and most of the people running the company either don't know, or are comfortable ignoring, the rules and regulations regulating their employees or insurance ( the c-suite is a who's-who of BearStearns, IndyMac, United, Optum and Amazon).

Since the team I was hired into was comprised of RN's and unlicensed or paramedical professionals (and were all generally performing the same work), the nurses had a lot of misgivings about having unlicensed or lower level credentialed staff working "under their license". The nurses were rightfully concerned about using the unlicensed and/or non-nurses to do work previously done by RN's, so the former Director and Senior Manager discussed in a staffing meeting that we weren't using our licenses in an "actionable way"; that direct patient care experience and having had a license during those years was all that was needed for the position.

In the interim I forgot to renew my license (it renews during my company's busiest time of the year), but had 3 performance reviews that all stated I was meeting the expectations and requirements of the role.

The Director of my Department was fired a year ago (for something unrelated) and the Senior Manager quit in September. The new Senior Manager (who has no experience in insurance or anything else my department does) started in December and everything was mostly hunky dory ( I got a great performance review from her 1 month ago, but there has definitely been some tension as she wasn't fond of the fact that the majority of the company treated me like the manager). Last week she flagged me about my license lapsing.

I explained my understanding of my role, but agreed to bring it back into good standing. She said I needed to take a PTO day to do it, which I also agreed to do. The next day she called with HR while I was driving to the state capital and said I was being fired for misrepresenting my license.

I have spoken with the previous Director since then and she said they were either relying on an old P&P or outright lying. She said the CEO personally approved of the updates to the job description. I believe this to be true, because the CEO asked my about "my thoughts' on using unlicensed or lower licensed professionals to do the work. There was at one time 4 unlicensed or lower level credentialed people doing the same work, currently one person still on the team that doesn't have a license at all (and makes 30% less than the nurses), and the company plans to outsource in July most of its utilization review to the Philippines and India (and why I think I was really fired; because I wouldn't downplay what they were doing.).

I'm sorry this is so long, but I'm freaking out that they may try to report this against my license. I don't think I did anything that would cause myself liability, but that's a serious allegation nonetheless.

Specializes in ED, ICU, MS/MT, PCU, CM, House Sup, Frontline mgr.

OP: Since no one who is currently a case manager responded, I will. When you were not licensed you may have risked the company's liability. You will need to talk to a lawyer about your situation to receive good advice.

Specializes in Med Surg, Tele, PH, CM.

This entire situation sounds scary. I am not understanding exactly what it is that your company does, but sounds more like a slick business deal than an entity that cares about their patients. Philippines? Seriously? Bottom line here is that it might be better for you if you get your license renewed and get a real nursing job. Sounds like you have skills, shouldn't be difficult.

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