d'cm

Could nurses be change agents? Theoretically yes, practically.. NO. In my 30yrs experience I have found nurses to be highly risk adverse and almost universally corporate compliant. The most jarring example is the story of Charles Cullen, R.N. who murdered hundreds of patients in hospitals in NJ. Nurse administrators covered it up and obstruction the investigation and untold number of nurses must of looked the other way.

One of things people don't realize is that private health insurance is one of the primary reasons healthcare in the US to be so expensive. In a market economy, price is a function of supply and demand. The payors (insurance companies) need ( demand) to have providers in their network or they will lose their contracts with employers who pay them. Providers obviously know this so they band together to get more leverage over the insurance companies. Employers and employees have little say in what they pay ( even employees of insurance companies - go figure). Now in regards to denials; I spent most of my career in UM and strongly believe the over utilization and non evidence base practice is a big problem, but the willynilly preauth system is a ridiculous way to address it. Single payer solves both these problems IF done right.

*The Role of Artificial Intelligence in Hospital Medical Management and Utilization Review** In recent years, the healthcare industry has witnessed a transformative shift with the integration of Artificial Intelligence (AI) into various aspects of medical management and utilization review. AI, with its ability to process vast amounts of data, identify patterns, and make predictions, has the potential to revolutionize how hospitals manage patient care, optimize resource allocation, and ensure efficient utilization of medical services. This essay argues that the use of AI in hospital medical management and utilization review is not only beneficial but essential for improving patient outcomes, reducing costs, and enhancing operational efficiency. ### Enhancing Patient Care and Outcomes One of the most significant advantages of AI in hospital medical management is its ability to enhance patient care. AI-powered systems can analyze patient data in real-time, providing healthcare providers with actionable insights that can lead to more accurate diagnoses and personalized treatment plans. For instance, AI algorithms can sift through electronic health records (EHRs) to identify patients at risk of developing complications, such as sepsis or heart failure, before symptoms become apparent. Early detection allows for timely interventions, which can significantly improve patient outcomes and reduce mortality rates. Moreover, AI can assist in clinical decision-making by offering evidence-based recommendations. For example, AI systems can analyze medical literature, patient history, and current treatment protocols to suggest the most effective therapies for individual patients. This not only improves the quality of care but also reduces the likelihood of medical errors, which are a leading cause of patient harm in hospitals. ### Optimizing Resource Allocation Hospitals are complex environments where resources such as beds, medical equipment, and staff must be allocated efficiently to meet the demands of patient care. AI can play a crucial role in optimizing resource allocation by predicting patient admission rates, length of stay, and the likelihood of readmission. By analyzing historical data and current trends, AI systems can forecast peak times for hospital admissions, allowing administrators to adjust staffing levels and bed availability accordingly. For example, AI-driven predictive analytics can help hospitals anticipate surges in emergency room visits during flu season or other public health crises. By proactively managing resources, hospitals can reduce wait times, prevent overcrowding, and ensure that patients receive timely care. This not only improves patient satisfaction but also enhances the overall efficiency of hospital operations. ### Streamlining Utilization Review Utilization review is a critical process in healthcare that ensures medical services are used appropriately and efficiently. Traditionally, this process has been labor-intensive, requiring healthcare professionals to manually review patient records and insurance claims to determine the necessity and appropriateness of treatments. AI can streamline this process by automating the analysis of medical records, claims data, and treatment protocols. AI-powered utilization review systems can quickly identify cases where medical services may have been overused, underused, or misused. For instance, AI can flag instances where patients receive unnecessary diagnostic tests or where alternative, less expensive treatments could have been equally effective. By identifying these inefficiencies, hospitals can reduce unnecessary healthcare expenditures, which is particularly important in an era of rising healthcare costs. Furthermore, AI can assist in ensuring compliance with regulatory requirements and insurance policies. By continuously monitoring patient care and treatment plans, AI systems can alert healthcare providers to potential deviations from established guidelines, reducing the risk of denied claims and financial penalties. ### Reducing Administrative Burden The administrative burden on healthcare providers is a significant challenge in modern medicine. Physicians and nurses often spend a considerable amount of time on paperwork, documentation, and other administrative tasks, which can detract from patient care. AI can alleviate this burden by automating routine administrative tasks, such as coding and billing, scheduling, and documentation. For example, natural language processing (NLP) algorithms can transcribe and summarize physician-patient interactions, automatically updating EHRs and generating billing codes. This not only saves time but also reduces the likelihood of errors associated with manual data entry. By freeing up healthcare providers from administrative tasks, AI allows them to focus more on patient care, ultimately improving the quality of care delivered. ### Ethical Considerations and Challenges While the benefits of AI in hospital medical management and utilization review are clear, it is important to acknowledge the ethical considerations and challenges associated with its implementation. Issues such as data privacy, algorithmic bias, and the potential for job displacement must be carefully addressed. Hospitals must ensure that AI systems are transparent, accountable, and designed to complement, rather than replace, human expertise. Moreover, the successful integration of AI into healthcare requires ongoing collaboration between technologists, healthcare providers, and policymakers. Training programs should be established to equip healthcare professionals with the skills needed to work alongside AI systems, and regulatory frameworks should be developed to ensure that AI is used responsibly and ethically. ### Conclusion In conclusion, the use of AI in hospital medical management and utilization review offers immense potential to improve patient care, optimize resource allocation, streamline administrative processes, and reduce healthcare costs. By harnessing the power of AI, hospitals can enhance their operational efficiency, deliver higher-quality care, and ultimately improve patient outcomes. While challenges remain, the benefits of AI in healthcare are too significant to ignore. As we move forward, it is essential to embrace AI as a valuable tool in the pursuit of a more efficient, effective, and equitable healthcare system.

Streamlining Utilization Review Utilization review is a critical process in healthcare that ensures medical services are used appropriately and efficiently. Traditionally, this process has been labor-intensive, requiring healthcare professionals to manually review patient records and insurance claims to determine the necessity and appropriateness of treatments. AI can streamline this process by automating the analysis of medical records, claims data, and treatment protocols. AI-powered utilization review systems can quickly identify cases where medical services may have been overused, underused, or misused. For instance, AI can flag instances where patients receive unnecessary diagnostic tests or where alternative, less expensive treatments could have been equally effective. By identifying these inefficiencies, hospitals can reduce unnecessary healthcare expenditures, which is particularly important in an era of rising healthcare costs. Furthermore, AI can assist in ensuring compliance with regulatory requirements and insurance policies. By continuously monitoring patient care and treatment plans, AI systems can alert healthcare providers to potential deviations from established guidelines, reducing the risk of denied claims and financial penalties.

started at 77k and after 11 yrs 88k. then they fired me.

It's just this sort of BS that makes nursing a uniquely crappy job.

Thanks for posting that. It was indeed a fair bit of entertainment.

So a bunch of employees at Thedacare in Wisconsin got a better offer at another hospital - Ascension. The employees asked Thedacare if they would match the offer and were told no, so they went to Ascension. Then Thedacare decided they didn't like that and went to court to stop them. The judge issued a temporary restraining order but lifted it a couple of day later. What blows my mind is just how totally self harming this action was by Thedacare. They had nothing to gain as it's unconstitutional to make people work for you and now they laid out a bunch of money for lawyers and totally showed their hand as to what they really think of their employees - who should all be looking for the door.

The best answers I have ever seen to this question can be found at : Nick Carmody JD, MS Psych (@Nick_Carmody)

Insurance company CM would definitely reduce your exposure to Covid - but not to regulatory BS.

It really depends on what population you will be working with. Insurance CM can be any number of different things e.g. Disease mgmt, inpatient your/DC planning, or LTC (MLTSS medicaid).

to build on Curious1997: The medical history appears to be entirely "per the patient", do we have any actual medical records to verify her statements?

I've had at least 20 jobs in 25 yrs mostly because I would get fired. I think that should be some kinda record. :-)

Has the thyroid been fully evaluated by imaging and blood work?

Doubting yourself is a good thing, it keeps you vigilant. Making a big mistake at this point would be far worse than just not getting everything done. Doubt others also, discharge planning is all about handing off care to some other agency so follow up follow up follow up.

for some reason I thought of this:

I doubt it was discrimination, just bad managerial skills. You'll find a lot of that in nursing.

let's do an ELISA test.

United sees nurses purely as an expense. If regulations didn't require us they would not hire them. Evidence of this is that they have been profiting BILLIONS every month but nurses see literal pocket change raises and bonus' .

I loved hospital cm - it was fast paced, fully focused work and hours flew by, but was terrible at the politics and thus was unsuccessful at it. I do long term care CM for MCO now, work from home, lots of autonomy and no pressure. - but little intrinsic satisfaction. Looking forward to retirement soon.

I've done both and there are a lot of differences. The core similarity is they both involve discharge planning and utilization review. The big difference is the professional/social/political interaction in the hospital can get very complicated. I found that there are strong financial factors in the hospital setting which interfere with doing the right thing. Not so at all on the payer side.

The most difficult? Knowing which of these duties is most important to someone over you and any given time. 2. Application of process improvement methodologies in evaluating outcomes of care 3. Coordination of communication with physicians, nursing, and staff of ancillary departments 4. Evaluation of care provided against the Length of Stay 5. Collaboration with Admitting to ensure accuracy of patient demographic and insurance information 6. Communication with patients and their families around medical plan of care and discharge plan 7. Assessment and plan for discharge needs and arrangements, including leading multi-disciplinary care conferences and morning 'flash meetings' in conjunction with Nursing. 8. Coordinates/facilitates patient care progression throughout the continuum. a. Works collaboratively and maintains active communication with physicians, nursing, and other members of the multidisciplinary care team to effect timely and appropriate patient management. b. Identifies and resolves delays and obstacles to discharge in a proactive manner. Collaborates with medical staff, nursing staff, and ancillary staff to eliminate barriers to efficient delivery of care in the appropriate setting. c. Seeks consultation from appropriate disciplines/departments as required to expedite care and facilitate discharge. d. Utilizes advanced conflict resolution skills as necessary to ensure timely resolution of issues. e. Collaborates with the physician and all members of the multidisciplinary team to facilitate care for designated caseload; monitors the patient's progress, intervening as necessary and appropriate to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost effective; facilitates the following on a timely basis: i) Communication of all elements critical to the plan of care to the patient/family and members of the health care team. ii) Completion and reporting of diagnostic testing. iii) Completion of treatment plan and discharge plan. iv) Modification of plan of care, as necessary, to meet the ongoing needs of the patient v) Communication to third-party payers and other relevant information to the care team vi) Assignment of appropriate levels of care vii) Completion of all required documentation in the IT Case Management screens, and patient records 9. Completes utilization management for assigned patients. a. Applies approved InterQual criteria as a guideline to monitor appropriateness of admissions and continued stays and documents findings based on department standards. b. Identifies at-risk populations using approved screening tool and follows established reporting procedures. c. Monitors length of stay (LOS) and clinical resource use on an ongoing basis. Takes actions to achieve continuous improvement in both areas. d. Refers cases and issues to physician advisor in compliance with department procedures and follows up as indicated. e. Communicates with financial counselors to facilitate covered day reimbursement certification for assigned patients. Discusses payer criteria and issues on a case-by-case basis with clinical staff and follows up to resolve problems with payers as needed. f. Monitors utilization of resources and reports to Manager. Captures and documents Avoidable Days in Case Management IT system. g. Issues Notices of Non-coverage per hospital policy. h. Provides Part B coverage notification for Observation patients. i. Uphold compliance of regulatory standards for Observation patients including CMS requirement for Code 44. 10. Manages all aspects of discharge planning for assigned patients. a. Meets directly with patient/family to assess needs and develop an individualized plan in collaboration with the physician. b. Collaborates and communicates with multidisciplinary team in all phases of discharge planning process, including initial patient assessment, planning, implementation, interdisciplinary collaboration, teaching, and ongoing evaluation. c. Ensures/maintains plan consensus from patient/family, physician, and payer. d. Refers appropriate cases for social work intervention based on department criteria. e. Collaborates/communicates with external case managers. f. Initiates and facilitates referrals to the Social Worker as defined in department policy. g. Documents relevant discharge planning information in the System Case Management. IT system according to department standards. h. Facilitates transfers to other facilities. i. Follows ED Case Manager Job Description and Performance measures when assigned to ED. 11. Finance a. Monitors bed availability on assigned unit in conjunction with nurse manager. b. Communicates OBSERVATION LOS to patient and family. Has patient/significant other sign Acknowledgement Form as to status and tentative discharge date and time. c. Initiates calls/communication to managed care companies, on all patients as required. d. Assist in calling for hospital test results in absence of timely reporting to help expedite patient movement. e. Solicits 'Patient Choice' for support services post discharge and confirms in EPIC. f. Monitors appropriateness of resource consumption including orders for CT and MRI. Refers variances to Physician Advisor. g. Knowledgeable about Indigent Medication Programs. Updates and posts list in Physician Lounge areas for physicians and hospitalists. h. Works in coordination with Registration to reduce number of clerical errors in patient status. Makes sure patient insurance correct as well as status. Notifies Registration of changes needed to produce accurate Face Sheet revisions. i. Refer appropriate patients to Financial Counselor. j. Calls insurance company for pre-approval of high cost testing when required. k. Applies Case Management Protocols as applicable. 12. Quality-Actively participates in clinical performance improvement activities by: a. Assisting in the collection and reporting of indicators tracking efficiency of case management processes. b. Use of data to drive decisions and plan/implement performance improvement strategies related for assigned patients, including fiscal, clinical, and patient satisfaction data. c. Collection of delays in service data and data for specific performance and/or outcome indicators as determined by the director. d. Solicits Physicians/Hospitalist in needs related to Case Management activities. e. Attends in-service programs relative to scope of care relative to management of chronic health conditions causing readmissions such as Heart Disease, Cancer, Respiratory Conditions, Arthritis, Hypertension, Diabetes or Depression. f. In the process of chart review screens orders and entries for appropriate signing, pended orders and dating as required by The Joint Commission/CMS. (CPOE)written. g. Practices hospital service initiatives to improve HCAPPS scores. h. Arrange home medications for patients to avoid unnecessary admissions. i. Makes timely referrals to discharge entities as required. Makes referrals to Social Worker as outlined in policy. 13. Service a. Calls and communicates with major payors to discuss pitfalls and problem cases and documents interventions in Case Management IT system. b. Attends unit and committee meetings as required. c. Prioritizes expedition of Observation patients on units. d. Provides relief coverage update on patient caseload and concerns. e. Coordinates 'end of life' discussions with physicians related to patient needs, if indicated. f. Calls and arranges transportation arrangements for patients on discharge. g. Assists in notification of bed availability and readiness on respective unit and communicates to appropriate personnel. h. Notifies patient of hospital discharge time and documents date and time of patient agreement on whiteboard in patient room. i. Confirms with attending physician consultants have signed off case. 14. Growth a. Uses Interqual Guidelines as a coaching tool to aid physicians /hospitalists in appropriate placement of patients. Consults with Physician Advisor as appropriate. 15. Adheres to the Medical Center's Organizational Competencies and the Standards of Behavior.

The actual work of an insurance company case manager is tightly defined by the company. Going in with preconceptions could be counterproductive. The only thing I would suggest is making sure you know how to use Outlook, Word, and Excel.

Apply at United Healthcare. They are always hiring field case managers.

of course they supply computer. think HIPAA.