Utilization management nurses

banditrn · Sep 29, 2006

To do the job you do, you really have to know your stuff!! Don't let them get to you - they probably wish they could have your job! :yeah:

rach_nc_03 · Sep 29, 2006

hi indynurse,

working for an insurance company now (I'm in clinical program design, so I interface with the review nurses), I see just how much knowledge one has to have to work as a nurse in this sector. Don't let anyone look down on you for it! My sister interfaces with UM nurses in her job for another insurance company, and she told me, 'can you imagine what it would be like if the people making all these decisions *weren't* nurses? how would that make you feel as a patient?' I think it really draws on your critical thinking skills, creativity, and broad knowledge base. You have to constantly keep learning, right? And let's just think about a few examples of non-hospital/bedside nursing jobs:

Utilization review

Case Management

Telephone Triage

Consulting (which is what I do)

Research

Educator (community, facility, etc.)

Staff Development

Informatics

Why is it that people don't balk when physicians have jobs that aren't hospital patient care-centered? I think a lot of people- even some nurses- don't realize or think about the fact that healthcare extends *FAR* beyond the hospital bed...and so does the need for nurses.

(My latest plan is to get my MSN in Nursing Informatics, what with all the legislation about electronic health records- there's going to be a HUGE demand for nurses in this field in the coming years!)

Oh, and don't apologize because you didn't like bedside nursing. Plenty of people don't! It doesn't mean you're worse (or better) than soemone who loves it- just different than they are.

I went to a Disease Management conference a couple of weeks ago, and let me tell you- the future is wide open for you if you decide to do other things than UM. Don't ever feel embarassed by what you do! So far, I'm loving my new job, too!!

To your original question, here's how I answered, when asked by a nurse at the hospital where I had an MRI why I 'gave up' on being a bedside nurse:

'Since everyone goes into nursing to have a positive impact on the health and well being of the patients in their care, I decided I could have the greatest impact in an area I was passionate about.' She thought about it for a second, then said, 'well, I never really thought about doing anything besides what i do now- you've given me something to think about!'

And (this is not meant as a slam to anyone, honestly), the money is usually pretty good in the insurance sector- and you don't run yourself into the ground physically like is so common in hospital staff nursing. I'm making more than double what I made at the bedside, and I have a desk job. I have a serious hip problem that would probably preclude beside nursing, even if I wanted to do it, so that's a HUGE plus for me.

Heh- I could go on and on, being a cheerleader for ya!

Last comment- I'm having major surgery next month- I can't tell you what a huge relief it is to me to know the knowledge and skill level the precert nurses at my company have. I'll be in the hospital most of the week, and I was initially concerned about being approved for it, but I knew the person making the decision was a well-educated nurse who could appreciate the complexity of the situation.

Be proud- other people may not really understand your job, but you ARE a nurse, and your practice is essential to the patient's care!

Elisheva · Sep 29, 2006

If you leave your job, let me know. I'd like to apply for it.

Don't waste your time worrying what those other people think. They're probably just jealous. If you're happy, that's all that matters.

icugirl33 · Sep 29, 2006

Hello,

I heard the same thing when I decided to leave bedside after 9 months. I too work for a health insurance company, and work 2 weekends a month at another company doing telephone triage. I am putting my nursing knowledge to use, just in a way I enjoy more. I have so many choices as a nurse, I feel like a kid in a candy store. In the 9 months I worked bedside, I worked 5 months in Tele, 4 months in the E/R, and less than a month in rehab. I love what I'm doing now!!

Good luck

AuntieRN · Sep 29, 2006

Hey...they teach us in school even that bedside nursing is not for everyone. I agree with the other posters. Can not even imagine what kinds of decisions would be made if they were made by nonnursing personel. Hold your head up high and be proud of yourself and your new job. They are probably just jealous they did not think of it first.

cookie102 · Sep 29, 2006

i'd like to know how to go about getting a job with an insurance company, i would love to do precertifications

CseMgr1, ASN, RN · Sep 29, 2006

I was a UM nurse for 4-1/2 years before I quit, as Management shifted its focus from quality to quantity. I simply could not keep up the pace and my sanity at the same time. Just because I couldn't, doesn't mean that those of you out there who are interested in UM can't. I just got tired of working for people with an increasing sweatshop mentality, that's all.

indynurse#2 · Sep 29, 2006

THANK YOU all for your comments and encouragement! You have made my day :wink2:

lcprnc · Sep 29, 2006

I was initially a UM nurse for a Mental Health facility, then I wore another hat...UM for the insurance (HMO) co. It's a very challenging job but I also think rewarding. It also opened my mind into the "business" aspects of health care. You are the person who need to balance quality and cost of services, be a patient advocate but at the same time, ensure that services are not duplicated and patients receive continuity of care. As an RN doing UR/UM, your knowledge of patient care is very valuable when it comes to balancing cost and quality. Bedside nurses tend not to see this. They see the patient on that bed and usually, their goal is to get them medically stabilized and to get them out. Utilization review can expand to case management responsibilities...discharge planning is a big issue, placement, cost, and doing your best to prevent re-hospitalization of the inpatients such as arranging for DME, home care, and other resources that are available out in the community. You also always explore for the lower level of care to coantain cost. I would suggest that you look into obtaining a case management certification. Then, you can add "CCM" or certified case manager after your RN :) Don't worry about what others say. They just need to look outside of the box. - LCPRNC, also a CCM

needrn · Sep 29, 2006

I was initially a UM nurse for a Mental Health facility, then I wore another hat...UM for the insurance (HMO) co. It's a very challenging job but I also think rewarding. It also opened my mind into the "business" aspects of health care. You are the person who need to balance quality and cost of services, be a patient advocate but at the same time, ensure that services are not duplicated and patients receive continuity of care. As an RN doing UR/UM, your knowledge of patient care is very valuable when it comes to balancing cost and quality. Bedside nurses tend not to see this. They see the patient on that bed and usually, their goal is to get them medically stabilized and to get them out. Utilization review can expand to case management responsibilities...discharge planning is a big issue, placement, cost, and doing your best to prevent re-hospitalization of the inpatients such as arranging for DME, home care, and other resources that are available out in the community. You also always explore for the lower level of care to coantain cost. I would suggest that you look into obtaining a case management certification. Then, you can add "CCM" or certified case manager after your RN :) Don't worry about what others say. They just need to look outside of the box. - LCPRNC, also a CCM

HI, can you tell me how can an RN get to be a CCM? I have been a tele nurse for a year, and I really think bedside is not for me( I also have a business degree and have done finance/sales in the past)...Also, how much experience do you need to apply for an insurance job?....In my area (Central New York) they seem to be hard to come by....Thanks!

smir953328 · Mar 3, 2008

Check out below website for CCM. It has all the info you need to obtain your CCM.

http://www.ccmcertification.org/

Sylvia