Nurse Case Manager

As a Nurse Case Manager with well over twenty years experience within this profession, I can attest to many changes in this area of Nursing Practice within the Health Industries. I can also say that everything old is new again.

I have been fortunate to manage the care and help our Veterans better understand their health care benefits, care management and wellness. It has truly been a blessing to be provided this insight from my veterans.  I have learned more from them they have from me. #HowILead

Nurse Case Management has advanced from the days when we were called Utilization Review nurses and had to know the cost of things, check documentation, educate, inform, advise, negotiate and check again. This has not changed.

We Had to know Interqual-criteria like the back of our hand.

The Severity of Illness and Intensity of Service, various insurance companies and entities, rules and regulations. We learned to teach this "different language" to our physicians and fellow case managers and staff.

Additional guide lines along the way were M&R to Milliman guidelines. We always had to keep up to date.

CMS-Medicare and Medicaid, which are changing day to day, from Observation to the endless 2 midnight rules.

Perhaps, if Case Managers were permitted to Case Manage their own patient, boots on the ground, we might just get some real change that is accurate, sustainable and real for the patient. Because we work as a single unit or team.

We as Case Managers still do this and more!

But what is constant is the Doctor's Judgement; it rules the day!#HowILead

We also have to know how, if, or when to Challenge the Diagnostic Related Group (DRG) and the ICD-9-10, the DSM-5 coding, which we know can make or break a claim. (We still do this.) We, learned how to appeal any claim; to the first and second levels and win 89% of the time.

I have kept that knowledge with me and taught it to the Nursing and physician staff along my way.#HowILead  

I can say that the bedside nurses that I have had experience with, do know what things cost and improved outcomes with me.

The staff also believed we were OZ!

But as we always joked, "I am just the fat man behind the curtain."

An example; they were horrified to find out that room and board in an acute care facility; was $8000.00/day and that one single aspirin cost $5.00.

Sometimes, the truth is the truth and it requires transparency.

They also learned that Chest Pain is a symptom not a diagnosis!

Case Managers are now the autonomic nervous system for the Healthcare Industry!

If your Industry does not have one now, I Highly recommend that you grab both a Nurse case manager and a Social Work Case Manager.

• We are the warriors that fight the good fight for whomever our client maybe.
• We have grown to become very knowledgeable and highly skilled.
• We do our very best to save on the cost of care.

Each and every CEO with over 20b0 employees for whom you pay insurance for, you should have a Case Manager within your own Industry.

Unless, of course you are not interested in retaining healthy employees or saving money.

Here are some of the reasons you need one in human resources:

• 1. We Case managers focus on care collaboration and problem solving
• 2  We Case Managers provide financial management, and resource utilization to yield cost-effective outcomes that are patient-centric and safe.
• 3. We Case Managers provided the right care at the right place, in the least restrictive setting, in the patient’s disease process.
• 4. We Case Managers support and guide our patients, families, and stakeholders and are viewed as essential members of the team.

Case management is a fluid and dynamic practice that is most effective when it changes and adapts with the challenges of the healthcare system.

Stewardship of the healthcare dollars, safe transitions of care, evaluating patient adherence, and consistent stakeholder communication are critical interventions that case managers employ, while maintaining a primary and consistent focus on quality of care and patient self-determination.

So in all true honestly, everything that is old is sometimes new again and visa versa!

~Kimberly

Photo Credit Google images

P.S. This one is a test as well.