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

**Lunah**, MSN, RN

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!

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

About Lunah, MSN, RN

Share on other sites

More Like This