Nursing Case Management and the Utilization Review Role

The Many Duties Under Case Management

Care management
Care management is about managing resources and time
Case management is the process of matching the resources available to the needs of the individual patient in such a manner to enhance the quality of patient management and patient satisfaction. Nursing Case Management  has held a relatively low-profile position in the field of health care till the latter half of the 20th century. The cost effectiveness and continuity of patient care is increased through utilization review and discharge planning. Case management nurses form an important part of the healthcare team.
Nursing Case Management ensures that a patient receives the most effective health services by being in touch and communicating with the patient, the doctor, the health care providers, and the other allied health care services such as insurance. The duties of a case management nurse include the following: They act as care coordinators between the doctors, therapists, dieticians, specialists, etc., and develop an effective working relationship. They record the symptoms, perform the diagnostic tests, and collect all details about the vital signs of the patient. Promote the efficient and effective utilization of clinical resources. They constantly communicate with the doctors and insurance companies. Ensures adequate care for the patient during the hospital stay and facilitates timely discharge. Conducts review for appropriate utilization of resources and services from the instance of admission of the patient through discharge. Makes sure that the patient does not get more than necessary care. Facilitates a relationship between the family and the patient to enable them to take informed decisions.
Case management nurses are RN’s who have undergone specialized training or have completed certificate programs in case management. On completion of the program the certificate is issued if the candidate has a current valid RN license, has an experience of two years as a full-time RN, and has worked for 2000 hours as a case management nurse in the last three years. Though the additional training is not always compulsory, jobs in specialized health care settings do require the specialty training.
Skills required to be a successful case management nurse include all skills required of a medical job, communication skills, the ability to respond quickly to medical emergencies. The case management nurse is expected to gain knowledge about diagnosis related group codes (DRGs), develop critical thinking, be observant and keen and improve the ability to analyze. Certified case managers are always paid a higher salary than other nursing professionals. A case management nurse earns an average salary between $55000 and $75000.
The average salary of a Case Manager Nurse is $55,000 to $75,000
The average salary of a Case Manager Nurse is $55,000 to $75,000
The job of a case management nurse is much in demand as hospital stays of patients are becoming much shorter. Role of a Utilization Review Nurse A utilization review nurse reviews individual medical cases to ensure that they are getting the most effective care. Such utilization review nurses work for the hospitals and sometimes for insurance companies in an advisory capacity and decide whether specific care for the patient is to be approved or not. They balance the needs of the patient to make the entire episode of care to be one that is cost effective, enforce policies and are instrumental in providing care that is suited to the needs of the individual patient. Working as a utilization nurse may involve situations when the cost issues have to be weighed against the obligation of providing care to the patient. They may have to approve or deny a specific method of treatment, a diagnostic test or a medication to the patient as per organizational guidelines. Utilization review nurses review requests pertaining to hospitalization of patients, medical imaging tests, recommended medical procedures and also whether the cases meet the standards for reimbursement of claims by the insurance companies. They ensure that patient care stays at specific levels and make adjustments in case of changes that may occur.
A utilization review nurse must be a qualified RN, at the baccalaureate level, and must have some minimum experience in the field of case management nursing. The skills associated with this job includes the ability to work under stress, be able to work independently without supervision, keen observation and attention to detail, be able to work with large amounts of data, ability to analyze and decisiveness. Utilization review nurses earn an average salary of $75000 per annum, a pay that is higher than what most RN’s earn.
If you are interested in Case Management Certification, please review the program.