Utilization Review Learning the Ropes

[WVrnmom]

Currently I have been in my job for less than one year. My concerns are I feel that I am just not quite understanding what all I do, more of the reasons why behind some specific tasks. My supervisor's area of speciality is coding and to my knowledge she has never done my job in its entirety. We seem to be on two different pages at all times, and when I started the job, I felt as if she just expected me to understand it. In our facility, we use Interqual, I also send charts to EHR when I am unable to make the determination. I have several reports I must provide, like our Observation Stays, and Short Stays( anything that was made an IP that was, a one day stay). I am looking for any written information out there on Utilization Review. This is a job one cannot learn in nursing school! So far the only thing provided to me is Webinars on the "two midnight rule"! Managing those Observation stays is tricky when you don't work seven days a week!

[SummerGarden, BSN, MSN, RN]

If you are having a hard time with reviews you can ask your manager to pay for training through McKesson. If your confusion stems from a lack of established protocols to follow, then this is a problem with your leadership team (You do not have the right kind in place).

Within the CM departments I work there is strict guidance as to what is considered priority and how to deal with various cases. Neither job mirrors the other in protocols with the exception of following CMS and other governmental regulation guidelines that must be followed. Otherwise, cases are handled a particular way by the organization for reasons that reflect what the leadership deems is the best way to get reimbursed. With that said, I think you have two choices.

In the past, many poor leaders were sent to Case Management departments before he/she retired. However, over the past 5 years there have been many changes that reflect reimbursement to hospitals by insurance companies, Medicare, and Medicaid. So much so, Case Management is now deemed important! Thus, the new trend is to fire the poor leaders of Case Management and Utilization Review departments and to replace him/her with those that are hard working, know and understand this specialty, and who are able to establish protocols that follow regulations while maximizing the institution's reembursement rates. Therefore, you can either 1.) wait until this person is replaced with a competent manager or 2.) you can find another job.

By the way, a good place to understand regulations is to read the CMS website, learn about the ACA (Obama Care), and read evidenced based publications on this field (there are Case Management journals that come out monthly that will be of some value to you). Either way, good luck to you. :)

[WVrnmom]

Thank you for your help, I truly appreciate it. Our previous UR Nurse was never allowed to go to any training, because of course that is an expense. So far no help has been offered, and training has been turned down when I have asked.

[SummerGarden, BSN, MSN, RN]

Thank you for your help, I truly appreciate it. Our previous UR Nurse was never allowed to go to any training, because of course that is an expense. So far no help has been offered, and training has been turned down when I have asked.

The other thing you can do if you do not wish to quit your current job is to find a job Part-time or Per Diem position that will pay for the McKesson training, then apply your knowledge to this job. I know of a nurse CM whose environment was changing protocols and procedures but had the nerve not to provide any training to help the CMs adjust to the change. So she took a job with a large competitor of her hospital system several years ago and gained a lot of knowledge and training that way. She still works for the other employer Per Diem to keep up with changes and training.