Utilization Review and RNs

[jstbg1s]

For the past 5 months while out for injury(on the job) my light duty work was to do utilization review, case management, chart audit, and such. The position was open and about a month after I was doing it, my employer posted it to find a permanent replacement. I applied and was told I would need to be an RN. My supervisor then informed HR she would be happy for me to work under her license while I finished up RN school (Im an LVN now). I was told I was being seriously considered for the position but did not get it. I had the pleasure of training my replacement today after five months on the job. She does not hold any nursing degree nor will be attending school for it anytime soon. She is a social worker. I have had a lot of difficulty helping her understand the relationships of medical necessity. I live in Texas and I thought you had to be an RN for the job or at least have a nursing degree......does anyone know different? I don't mind not getting the position, but don't understand the reasoning. Any information anyone has on this would be helpful. I guess my biggest concern is for possible fraud of medicare and abuse of the system. With decisions like this how can we expect people to recieve the best care possible? :trout:

[grammyr]

If you will look at the Conditions of Participation in Medicare guidelines, I think I saw something in there that relates to this. If not, pm me and I will find the regs.

[ASSEDO]

i have looked in the cms website, www.cms.gov (under manuals) publication 100-08 medicare program integrity manual and i failed to find where cms requires an rn for medical review. i know they fail to require the mr manager to be rn; or as a degreed person. the medicare mr manager can be anyone off the street, so to speak. however, most hospitals require a rn for ur. i am referring to medicare regulation because they are the big payers and usually set the rules for other insurance companies.

[leslymill]

I would think a social worker would just have better things to do.

[nursingisacurse]

That's funny. The local hospital here in east Tx says has UR nurse pegged as a LVN position.

[green217]

Depending on the type of audit, some employers prefer RNs. An audit, such as RAC, can be challenged by the healthcare facility or a provider, specially if they stand to lose a lot of money. One of the things they can challenge is the competency of the auditor.

[Karl Farmer]

You don't need to be any kind of nurse for a whole SLEW of jobs that label themselves otherwise. But LPNs in fact hold a lot of UR jobs in insurance companies and HMOs. But really, UR is just coming down to a set number of days, after which the patient must be discharged or switched to private pay. The filed is just one of many being lost due to gains in IT. In the 19080's as an example, a nurse from the insurance company would even go to nursing homes, for care plamn meetings, to discuss progress, prognosis, and what not. Now, digital information is available, so the human factor is going bye bye. I also am hearing more that 'triage' by telephone is being done by unskilled people in Asia, simply to attempt to prevent customers from even thinking about going to an ER, vs waiting for a Monday appointment at the GP's office??