UM/UR hospital vs insurance company?

[rearviewmirror, BSN, RN]

Hello there all. I am trying to step my feet into the utilization review/management, and with only 3 years of clinical experience, I find it challenging to get into this. My hospital system has positions open for utilization review and of course, internal transfer is easier than trying to get into insurance companies.

So my question is, what is the difference between working in UR/UM with hospital system and insurance company? I pretty much vowed never to work for hospital again after this current ER job, but whatever can help me get my feet wet in this hard-to-get position, I am willing to work for whoever. What can you say from your experiences?

[lunanarya, BSN, RN]

I'm not a nurse (yet!) but have worked in a combined TCM/UR department for several years now as support staff that does independent reviews for other carriers for their workers' comp claims. From our angle, it's a big cost savings mechanism. Our UR nurses are basically in/out/done with each individual request for treatment, and if there is a TCM involved also, they'll frequently work together to coordinate whatever the request for treatment is for (the UR nurse will take care of the auth for the short term, then the TCM nurse will coordinate it and follow up on the patient's care for the long term.) It's pretty interesting work. They have very defined guidelines they follow. They often work with UM/UR folks at hospitals especially in cases where the patient is being d/c or moved to to a different facility for inpatient rehab, etc.

[rearviewmirror, BSN, RN]

thank you very much for that input lunanarya!

[Libby1987]

I worked UR for an insurance company. It was a good job, paid well and I was well treated. I performed onsite reviews and anticipated auth requests. The hospital dc planners/UR staff worked hard and their stress/productivity expectations seemed to be much higher than mine.

[rearviewmirror, BSN, RN]

I worked UR for an insurance company. It was a good job, paid well and I was well treated. I performed onsite reviews and anticipated auth requests. The hospital dc planners/UR staff worked hard and their stress/productivity expectations seemed to be much higher than mine.

such is reason my primary choice employer is insurance companies. haha thanks for your input!

[Been there,done that, ASN, RN]

Utilization review/management is a chess game between the facility and the insurer.

You will need to pick you pawn. Are you going to work for the hospital.. or the insurance company? Either position pays the same. You will be evaluating medical necessity for admission.

Thinking that if you can get a position within your facility... go for it. I work on the insurance side... I live to deny payment.

[JVLims]

I'm a hospital case manager and have UM as part of my blended role. I would always choose to work in a teaching hospital as you continue to hone your clinical knowledge in an intellectually stimulating atmosphere while working on behalf of both the patients and the hospital to ensure both best patient outcomes AND most responsible resource use. I would prefer to work as a patient advocate rather than work on behalf of a private company's shareholders. I love the hospital environment and would dislike moving to a more business based work environment.

[rearviewmirror, BSN, RN]

Utilization review/management is a chess game between the facility and the insurer.

You will need to pick you pawn. Are you going to work for the hospital.. or the insurance company? Either position pays the same. You will be evaluating medical necessity for admission.

Thinking that if you can get a position within your facility... go for it. I work on the insurance side... I live to deny payment.

hey been_there, would you be able to guide me into an interview situation and give me some pointers, what they would ask and such? I am rehearsing myself all sorts of questions from general to detailed with answers and experience stories include (i.e: tell me about time when you... and so on). Thanks :)