Psychiatric Nursing Positions in Managed Care

By Nash, Kris | Perspectives in Psychiatric Care, October-December 2000 | Go to article overview

Psychiatric Nursing Positions in Managed Care

Nash, Kris, Perspectives in Psychiatric Care

Career Perspectives discusses alternative careers for psychiatric nurses. This column explains the variety of roles for nurses in a managed care organization, and outlines two of the more common and important roles of precertification nurse and case manager.

   UR Nurse wanted for behavioral health case management. Managed Care
   Behavioral Health Organization seeks psychiatric nurse--UM experience

Employment ads with puzzling acronyms seem to crop up with increased frequency as managed care and HMOs increasingly become the most common type of health insurance coverage for Americans. More than 78 million Americans are now covered by HMOs, a number that is predicted to rise 28% by the year 2005 to more than 100 million (Sussman, 2000).

The most effective organizations focus on keeping patients healthy by emphasizing preventive care and providing a holistic range of benefits. They have strong quality-improvement programs and offer a variety of disease-management programs. They have well-trained and effective case managers and visionary leadership. They constantly strive to improve the process. The leaders think "outside the box" and listen to their stakeholders (members, providers, employees). Traditional indemnity insurance is fast becoming a dim memory for many, and it is completely unknown to many entering the job market today. Like it or not, managed care in some form appears to be here to stay. Where do nurses fit in today's managed care organizations?

As hospital beds decrease in number and psychiatric and substance abuse centers close their doors, many nurses, particularly those in more rural areas, are forced to consider a career switch from the traditional role of hospital-based nursing. Managed care organizations increasingly present unique job opportunities for nurses, with many new positions that did not exist 5 years ago. Many are niches carved out by nurses themselves who recognized gaps in the managed care process or an unfulfilled need in the organizations.

Nurses work in many areas of managed care--for example, utilization review, quality management, claims review, network management, and member education/health improvement. Nurses also write policy and procedures; conduct internal and external audits for regulatory compliance; or work in legal and risk management, provider relations, coordination of care, and case management, to name just a few. Behavioral health may be done in-house by a behavioral health vendor who specializes in this area, or by an insurance company that creates a wholly owned subsidiary specifically for this purpose. This article will address utilization management, or utilization review and case management, in a managed care environment. Both are areas that usually require at least an RN license. Many organizations prefer a master's or licensed professional counselor degree. Department directors and clinical management positions may require a doctorate.

Utilization Review/Management

One way HMOs manage care is through utilization review (UR), also referred to as utilization management (UM). UM often is considered the "nerve center" of the HMO, as cost of care consumes on average 80% of the premium dollar and is the most crucial financial aspect of the HMO's bottom line. The demand is rising for skilled nurses with medical and/or psychiatric nursing experience to fill these positions. At its most basic, UR consists of reviewing clinical information and making a determination of medical necessity within coverage guidelines using established criteria.

Behavioral health presents unique challenges to the nurse reviewer, because the clinical information presented tends to be subjective rather than medical criteria, which are normally objective, and measurable clinical data. Additionally, many states have confidentiality laws that limit the amount of information that can be given to behavioral health UM to determine medical necessity.

The rest of this article is only available to active members of Questia

Sign up now for a free, 1-day trial and receive full access to:

  • Questia's entire collection
  • Automatic bibliography creation
  • More helpful research tools like notes, citations, and highlights
  • Ad-free environment

Already a member? Log in now.

Notes for this article

Add a new note
If you are trying to select text to create highlights or citations, remember that you must now click or tap on the first word, and then click or tap on the last word.
One moment ...
Project items

Items saved from this article

This article has been saved
Highlights (0)
Some of your highlights are legacy items.

Highlights saved before July 30, 2012 will not be displayed on their respective source pages.

You can easily re-create the highlights by opening the book page or article, selecting the text, and clicking “Highlight.”

Citations (0)
Some of your citations are legacy items.

Any citation created before July 30, 2012 will labeled as a “Cited page.” New citations will be saved as cited passages, pages or articles.

We also added the ability to view new citations from your projects or the book or article where you created them.

Notes (0)
Bookmarks (0)

You have no saved items from this article

Project items include:
  • Saved book/article
  • Highlights
  • Quotes/citations
  • Notes
  • Bookmarks
Cite this article

Cited article

Citations are available only to our active members.
Sign up now to cite pages or passages in MLA, APA and Chicago citation styles.

(Einhorn, 1992, p. 25)

(Einhorn 25)


1. Lois J. Einhorn, Abraham Lincoln, the Orator: Penetrating the Lincoln Legend (Westport, CT: Greenwood Press, 1992), 25,

Cited article

Psychiatric Nursing Positions in Managed Care


Text size Smaller Larger
Search within

Search within this article

Look up

Look up a word

  • Dictionary
  • Thesaurus
Please submit a word or phrase above.
Print this page

Print this page

Why can't I print more than one page at a time?

Full screen

matching results for page

Cited passage

Citations are available only to our active members.
Sign up now to cite pages or passages in MLA, APA and Chicago citation styles.

"Portraying himself as an honest, ordinary person helped Lincoln identify with his audiences." (Einhorn, 1992, p. 25).

"Portraying himself as an honest, ordinary person helped Lincoln identify with his audiences." (Einhorn 25)

"Portraying himself as an honest, ordinary person helped Lincoln identify with his audiences."1

1. Lois J. Einhorn, Abraham Lincoln, the Orator: Penetrating the Lincoln Legend (Westport, CT: Greenwood Press, 1992), 25,

Cited passage

Welcome to the new Questia Reader

The Questia Reader has been updated to provide you with an even better online reading experience.  It is now 100% Responsive, which means you can read our books and articles on any sized device you wish.  All of your favorite tools like notes, highlights, and citations are still here, but the way you select text has been updated to be easier to use, especially on touchscreen devices.  Here's how:

1. Click or tap the first word you want to select.
2. Click or tap the last word you want to select.

OK, got it!

Thanks for trying Questia!

Please continue trying out our research tools, but please note, full functionality is available only to our active members.

Your work will be lost once you leave this Web page.

For full access in an ad-free environment, sign up now for a FREE, 1-day trial.

Already a member? Log in now.