Transition from insurance CM/UR to hospital CM/UR possible?

SummerGarden, BSN, MSN, RN · May 6, 2019

I am no longer a CM, however I performed the role for many years. Yes, an insurance CM can transition successfully to a hospital CM role. The insurance part will be helpful to performing UR. If you need to be a discharge planner in the hospital setting, I foresee that to be your only learning curve.

In any case, I know of RNs who worked for insurance companies that they liked and transitioned to the hospital setting. Most were not happy because they did not care for the number of UR cases they had to complete in a day. Those who were both a discharge planner and a UR nurse were not happy with the combined expectations.

Good luck to you. Some of my favorite CMs were the ones who transitioned from insurance companies. Those that were happy I more than welcomed because they had a lot of regulatory knowledge that was extremely helpful.

PlayLikeAGirl · May 11, 2019

Thank you so much for responding! It's good to hear that the transition can be made, so I will consider this option.

gonzoRN, MSN, RN · May 19, 2019

I spent almost 6 years as an insurance UM nurse doing inpatient UM, and last year, transitioned to hospital UR. It wasn't difficult, however, it definitely took some adjustment. Specifically, the physician/RN relationship. On the payer side, it was a MUCH more collaborative and respectful relationship. On the hospital side, it's pretty confrontational, particularly as it applies to observation vs inpatient. That may be a function of the culture at the hospital I work in, but it is definitely a down side, the lack of respect for UR nurses.

jsnbsn · Jun 12, 2019

If you think of Hospital CM and Insurance CM as mirror-images of each other, you may find transitioning easier. Both CM's are trying to save dollars for their employer -- but in different ways. But the most important thing for ANY health-care provider should be the desire to ensure that you have done your best for your patients.

It may be easier to transition from Insurance to Hospital CM work. As an Insurance CM, you know a lot of the criteria and "buzz words" that the carriers want. So, you should have a better idea on how to approach your contact with the Insurance-CM who will be accepting the care of your hospital-patient. Before you call, think of the ways proper post-discharge care will help the insurance company save money.....such as essential DME to avoid potentially costly accidents in the home setting. You can even do quick checks on the Internet to compare the cost of correct post-discharge care, against the cost of surgical and/or medical treatment needed for otherwise preventable post-discharge incidents such as falls with fractures, infections, etc. I used pricing-techniques to successfully obtain DME, medications, etc for my patients. And made sure I reminded my employers of those savings.

Good luck on your transition. And just remember to focus on the patient, and knowing what you did was your BEST EFFORT.