Utilization management question

Please clarify.. utilization medication management nurse. I do not recognize that role.

Utilization management nurses look at the medical necessity criteria used for inpatient by Medicaid and Medicare and either approve the services or,if there is a question about the validity of ther services,refer the question to doctors for peer reviews

I mistakenly wrote utilization medication management...I meant utilization Medicaid management

OP: to answer your question in general, many case management jobs can take 1 year or more for a RN with a clinical work background to feel comfortable. In fact, the turnover is high for RNs new to this specialty within his/her first year.

On the other hand, UR only positions are a little different. Therefore, it may take up to 1 year to feel comfortable or it may take less time. A good person to ask is an experienced UR only nurse at the facility or organization for which you will be working. He/she should know what it takes to get up-to-speed and how long it should take you under normal circumstances. Good luck!

I don't do Medicaid. However, I do complex CM where I handle both the CM functions and the UM side of the case. First is it the actual review of records or the software that is confusing you? I am guessing it is the second and your learning curve will be dependent upon to a large degree how fast you can adapt to learning new software. My first experience was using interqual and then I had to learn Milliman. Each can be searched by the dx or procedure code. Then it is just a matter of looking at clinical to see if enough criteria is met for nurse approval. See if you can attend a training webinar for the software, that will certainly not hurt. Of course after those I also had to learn to use lexicomp and the NCCN criteria databases. Hang in there it WILL get easier and faster!

Thankyou for these tips!we use Alpha,I used to use Interqpual as an admissions nurse and you are right, it has a lot to do with the program you are using,Thankyou, how long did it take for you to get comfortable?

Thankyou, I feel much better after reading it can take up to a year...

I would say the interqual had a short learning curve of less than a month because it was basically check a box and get a green or red light. Milliman took a good 6 months to really be able to find stuff fast and write the rational.

I've been a UR nurse for about a year and a half for private insurance. I use Interqual, and although the functionality of the program is fairly easy to pick up on; applying the criteria properly for some cases can be challenging. For example, LTACHs. Under their complex medical criteria, you have a primary reason why they are in there--pain management or two IV ATB, for example. Then two comorbidities that are not considered chronic, these can include wound cares and respiratory adjustments etc. However there is some overlap between the two, and the focus can change while they are inpatient.

I do a lot of psych reviews too, and residential facilities/CD treatment can be challenging. The main reason here is that the services provided have to meet the Interqual criteria definition. A residential facility can provide acute services, for example.

It is very interesting to hear from everyone.I had no idea that this was such a complex field or that so many areas are really dependent upon it.I guess you just take for granted all the hard work other people are doing to support your field...

Now I get it! Utilization management is an entirely new role for nurses. They didn't teach us that in nursing school. I see you have Interqual experience.. definitely a plus!

In what setting are you learning this new skill? Is this your first 2 weeks after orientation?

You would need to focus on applying the clinical information to the Alpha criteria.

Do you also need to learn the product lines and the business rules, and the network rules?