Working From Home: What's it really like? A Day In The Life Of A Clinical Appeals Nurse

Have you ever wondered what it would be like to have one of those "remote" nursing jobs? Maybe you've even applied for a few. The idea of working from home is growing in popularity and applicants are increasing; competition is fierce! Here's a look into my typical workday as an appeals nurse for a large insurance company.

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Working From Home: What's it really like? A Day In The Life Of A Clinical Appeals Nurse

Your alarm goes off at 6:45 am. You groggily reach for your glasses, roll out of bed, and go to the kitchen to get the coffee brewing. Shortly before 7 am you open your office door and 30 seconds later, you are logged in and beginning to chip away at your daily workload, all while in your pajamas. You peruse your email for anything pertinent, then turn your attention to the first appeal of the day.

About an hour later you hear the household begin to stir, so you go to your team communication program and mark yourself as “away.” You feed the dog, get your daughter a cereal bar, her favorite breakfast du jour, and a glass of milk. You try to remember your ER resident spouse’s schedule for that day (working? Not working? Which shift?) and you fail, so you check your phone to see if he needs to be up or not. Oh, bonus! He has a day off, so he can take your daughter to daycare.

You head back to work, now on your second appeal. That first one got a little complicated because someone used both medical and pharmacy benefits for a medication, and the criteria aren’t the same between the two. But that’s fine, you got it sorted, and now you’re looking at a benefits case to see if there is a network deficiency so the patient can use their preferred, out-of-network physician.

By noon, you have typically prepped about four cases for physician review. Maybe one or two you have been able to “nurse-approve,” which means also updating a few systems and sending a couple of emails to make sure everyone is aware that the patient can have whatever it is that’s been approved — maybe a medication, maybe an MRI. The nurses can approve things, but never deny them; that is up to the medical directors.

You pull your next case for after lunch, scan it quickly to see if it’s workable (sometimes cases need to be returned to the analysts to correct issues), mark yourself as “away” again and go down to the kitchen. You make yourself the usual (toast with peanut butter and honey) and have your lunch. You quickly figure out dinner plans and remove a couple of things from the freezer to defrost. You take a quick shower and get dressed. Thirty minutes later, you’re back at your desk to start case number 5, knowing that your goal for each day is 6 cases and you’re in pretty good shape. Oh, wait — this case is missing some documents, so you pull them from another system and send them for imaging, then make a note in the case that you’re holding it for documents. You move onto the next appeal, a complex spinal surgery. You spend some time trying to determine if the instrumentation is approvable while also rooting through the clinical documentation to see if the patient was discharged from physical therapy. A notification pops up — company town hall meeting in 15 minutes. You dash off for a bathroom break and an afternoon coffee. You’re back at your desk before the live stream starts, and you put the meeting up on one screen while you continue to work on the other screen. Having two monitors is a lifesaver!

Later that afternoon you wrap up a final case for the day, an appeal for a patient who needs Remicade more often than the standard every-8-week frequency approved for maintenance treatment. You check your worklist to see that two appeals have been routed back for you to create the verbiage that will go in the final determination letter and to update various systems with approvals, if applicable. You spend a few minutes clearing your list and closing out cases. You trade a few messages with coworkers on your communication program and wish them a good evening. A final check of the email and you log off, your workday complete. You might have time to fold some laundry and get dinner started before heading out to pick up your daughter. Some days you have a grocery pickup scheduled on the way. You count yourself fortunate that long commutes, so often like painful bookends to a workday, are a thing of the past.

Does it sound exciting? Maybe not. Like so many ED/trauma nurses, I love a good adrenalin rush! But situations change, family needs change. I needed a job that could move with me from one state to another, and that also had a stable schedule for our daughter, and this job is a perfect fit. As a bonus, I found that I really like working in clinical appeals because every case is different, I only see each case for a brief time, and then it’s essentially gone forever. Now doesn’t that sound like the typical ER patient? It meshes well with my ER nurse ADD, I like the variety. I also enjoy learning about so many subjects, from spinal surgery to medications both common and more obscure, to prosthetic limbs, inpatient admission requirements, imaging criteria, you name it. Jack of all trades, master of none – you can take the girl out of the ER, but you’ll never take the ER out of the girl!

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Lunah

About Lunah, MSN, RN

(Editorial Team / Moderator)

Wife, mommy, stubborn ginger, Army veteran, former ED/trauma RN turned work-at-home nurse.

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Specializes in school nurse.

Hi.

A couple of questions concerning this specialty...

When you're an appeals nurse, who are you working for, practically speaking?

I've often wondered if you get pressured  to not approve "too many" things so as to keep costs down for the insurer. (Although I'm not sure what the difference between not approving and denying might be in the insurance biz.) Are these stats used in your performance evals?

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Specializes in EMS, ED, Trauma, CEN, CPEN, TCRN.
6 hours ago, Jedrnurse said:

Hi.

A couple of questions concerning this specialty...

When you're an appeals nurse, who are you working for, practically speaking?

I've often wondered if you get pressured  to not approve "too many" things so as to keep costs down for the insurer. (Although I'm not sure what the difference between not approving and denying might be in the insurance biz.) Are these stats used in your performance evals?

An insurance company pays my salary, but we are continuously reminded that the "members" (patients) are our priority. There is no incentive to deny anything, and we are specifically NOT to consider the costs of whatever is being appealed. We are audited on the accuracy of our clinical summaries — did we use the correct criteria, did we accurately capture what was being appealed and why, those sorts of things; also, did we meet productivity standards with enough cases in a certain time period. I have "nurse overturned" (approved) plenty of appeals, from multi-day NICU admissions to what I'm sure are very expensive drug infusions, and I have never been told I am approving too much. If criteria are met, they are met, period. We all go the extra mile to get the right information for a case, even if it means multiple phone calls to multiple people to get the information. We all have insurance, we know how painful it can be to get things sorted out, and sometimes it's nice to know there are people on your side. It's like that old hair club for men commercial: "I'm not only the Hair Club president, but I'm also a client." LOL.

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Specializes in Community Health, Med/Surg, ICU Stepdown.

Very interesting! Thanks for sharing. Do you ever have to deny claims? What are reasons that things get denied? If you don't mind sharing = )

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Specializes in EMS, ED, Trauma, CEN, CPEN, TCRN.
10 hours ago, LibraNurse27 said:

Very interesting! Thanks for sharing. Do you ever have to deny claims? What are reasons that things get denied? If you don't mind sharing = )

I don't deny anything — that's above my pay grade. ? Only the medical directors (MDs/DOs) can do that. Things I see that get denied are usually because requirements aren't met in the first place, like wanting a more expensive brand drug without trying a generic first, or wanting spinal surgery when imaging is relatively benign and the physical exam is normal. Drugs or procedures that are experimental or investigational (not proven in literature to be beneficial) may be denied unless a patient has cancer and there is potential benefit, depending on the plan coverage. Things that are excluded by plan coverage get denied, like bariatric surgery or IVF — it's not up to the insurance company, it's what the employer chooses to cover for employees. I have seen plans that cover obesity surgery ONLY if the patient has diabetes. You could meet all of our regular criteria and that plan still won't authorize it without a diagnosis of diabetes. It really is helpful to read your plan benefit document, as dense as that reading may be. I have learned a lot about health insurance! 

 

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Specializes in Community Health, Med/Surg, ICU Stepdown.

Thanks for the explanation! When I worked at a clinic where most of the patients had cheap insurance plans that didn't cover much of anything, I spent a lot of time arguing with insurance companies trying to get them to approve albuterol for someone with severe asthma, insulin for diabetes, etc, so I began to see insurance companies as evil.

But in the cases you described I see the rationale, especially someone wanting spinal surgery without even knowing what's wrong with their back! That sounds dangerous and unnecessary. So maybe it depends on which company. I would like to learn more. Keep sharing! = )  

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Specializes in EMS, ED, Trauma, CEN, CPEN, TCRN.
20 minutes ago, LibraNurse27 said:

Thanks for the explanation! When I worked at a clinic where most of the patients had cheap insurance plans that didn't cover much of anything, I spent a lot of time arguing with insurance companies trying to get them to approve albuterol for someone with severe asthma, insulin for diabetes, etc, so I began to see insurance companies as evil.

But in the cases you described I see the rationale, especially someone wanting spinal surgery without even knowing what's wrong with their back! That sounds dangerous and unnecessary. So maybe it depends on which company. I would like to learn more. Keep sharing! = )  

Regarding the medications, it boils down to the patients trying the alternatives first, or providing notes showing that they have tried them or showing that they are stable/well controlled for X amount of years on their preferred med. Formularies change all the time, drugs go on and come off of the formularies even mid-year, so it gets crazy. Take Praluent and Repatha, for example. Both are injectable meds for people with heart disease risk, they help lower LDL cholesterol. If Praluent is preferred but the patient has been taking Repatha for 5 years with positive effects on their cholesterol, that is what matters. Does anyone want to tell someone "hey, go try Praluent and if your cholesterol gets sky-high again, let us know" and risk that person "failing" Praluent with a cardiac event? Nope. Same thing with letting a person's A1c get up there again because Novolog doesn't work as well as Humalog did, but Novolog is preferred. Or hey, your MS has been stable on Avonex for 10 years, but now we want you to try Rebif. Again, not happening; no one wants someone's stable disease to get unstable. That is the great thing about appeals — we can put all that stuff in the case for the medical directors to use their clinical judgment so things can be approved for the good of the patients. 

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Specializes in Community Health, Med/Surg, ICU Stepdown.
4 hours ago, Pixie.RN said:

That is the great thing about appeals — we can put all that stuff in the case for the medical directors to use their clinical judgment so things can be approved for the good of the patients. 

Thats is awesome. I remember when they asked me what the patient had tried besides albuterol I was yelling that they tried breathing LOL I bet if I could have talked to you it would have gone smoother

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Specializes in OB.

@Pixie.RN how did you learn the ins and outs of clinical appeals?  Did you have prior experience with insurance company work or were you oriented as a total newbie?  Just curious.  Love hearing about all the different niches there are out there.

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Specializes in Certified Oncology Nurse with master's degree..

I love learning about "home" nursing gigs! Thanks for sharing!

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Specializes in EMS, ED, Trauma, CEN, CPEN, TCRN.
2 hours ago, LibraNurse27 said:

Thats is awesome. I remember when they asked me what the patient had tried besides albuterol I was yelling that they tried breathing LOL I bet if I could have talked to you it would have gone smoother

I am an ER nurse at heart and by training, so I often lack a brain/mouth filter. ? I feel you! 

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Specializes in EMS, ED, Trauma, CEN, CPEN, TCRN.
1 hour ago, LibraSunCNM said:

@Pixie.RN how did you learn the ins and outs of clinical appeals?  Did you have prior experience with insurance company work or were you oriented as a total newbie?  Just curious.  Love hearing about all the different niches there are out there.

Oriented as a total newbie! No previous appeals or managed care experience. Lots and lots and lots of training! We did provider (physician/facility) cases first because they don't have as many regulatory elements to keep in mind. Then we received training on member (patient) appeals. I think I was technically "in training" for about 9 months before my audits went from training audits to true quality audits, but I was doing a full load of appeals about six months into the job. It really takes time to learn.

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