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.
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. …