Managed care involves various procedures to influence medical care delivery, utilization, and quality in the US. Organizations contributing to managed care include disease organizations, public health departments, insurance companies, and hospitals. Managed care jobs include claims adjusters, utilization review auditors, medical case management nurses, inpatient coders, and discharge planners. The purpose of managed care interventions can range from saving costs to preventing future suffering.
Managed care refers to the many procedures undertaken by various companies to influence the delivery, utilization, and quality of medical care in the US. A company does not have to be fully committed to a managed service purpose to make a contribution to the system. Some organizations that contribute to managed care in some way include national disease organizations, city departments of public health, private health insurance companies, and hospitals. The purpose of any intervention given by an organization can range from saving costs, providing care to those most in need, or preventing future suffering. Different types of managed care jobs can include careers as varied as a hospital discharge social worker, a loss control statistician for an insurance company, or a supervisor for a home health agency.
Managed care jobs that seek to minimize a health insurance company’s exposure to certain types of claims include claims adjusters, utilization review auditors, and medical case management nurses. Claims assessors review claims for potential expenses and factors that may increase medical care and expenses, such as chronic illness, lack of social support, mental illness or a history of substance abuse. If he feels the claim requires more supervision than provided over the phone, a claims adjuster may hire a medical case manager to meet with the patient face-to-face and manage his or her recovery. Utilization review auditors are managed care tasks where insurance company employees audit and closely review claims flagged by the computer system as being higher than predicted for age, gender, disease code, or some other factor. of the patient.
Other managed care jobs seek to maximize a hospital’s reimbursement from Medicare, Medicaid, or a private health insurance company. For example, inpatient coders review patient records to document any additional diagnoses or treatments to be added to the final bill. In managed care jobs, often present in the public and private sectors, utilization review nurses review patient records to obtain approval from the insurance company’s claims adjuster for approval of additional days of hospitalization. In other cases, hospital utilization review nurses work to justify disputed charges to insurance company utilization review auditors.
Some managed care efforts seek to minimize a hospital’s losses resulting from Medicare and Medicaid limits on hospital stay lengths and ceilings for the cost of procedures or treatments. Thus, discharge planners work from a patient’s first day in the hospital to plan their discharge as quickly as possible. Discharge planners work closely with home health care agencies to provide ambulatory nursing care after hospital discharge. The availability of home health care agencies and durable medical equipment (DME) companies often allows a hospital to discharge a patient earlier than would be possible without ambulatory oversight.
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