Ranging from hospital-based roles to outpatient clinics to hospice to insurance companies, nurses today have more professional options than ever before. I have held healthcare-related positions for over 35 years and served as a registered nurse for over 20 years. I have worked in both in-patient and outpatient health care.
In 2009, I chose to become an RN Case Manager (RN CM) for an insurance company. RN CMs help members learn more about their conditions and medications, address symptoms, assist with contacting the provider, and provide information on general health and lifestyle factors.
I am part of a trial teleworker pilot program, and therefore my commute takes less than 5 minutes because I work in my home, which is like winning the lottery! I start my day walking to my coffee maker. I log in to my company computer system and check emails. Using the company’s electronic medical record case management platform, I assess my day. I have a daily list of member names or provider offices to call. I finish my coffee and prioritize my calls.
Next, I assess the size of the daily post-hospital queue — a long list of names of members who have recently been hospitalized and are now discharged home and need check-in calls. From 8 AM – 9 AM, I contact provider offices to verify follow-up appointment times. I do case research or administrative tasks during this time. I continue to assess my call schedule and prioritize my calls and manage my caseload numbers to fill my day accordingly.
Daily, I like to have at least 30 calls on my schedule, and my caseload monthly is 60 – 70+ open cases. Cases are ranked for acuity, and points are assigned accordingly. Acuity points are the department productivity metrics I review with my supervisor each month, along with my call and documentation audits. Case types are assigned a point value ranging from 1 to 6 based upon complexity. My monthly goal for case acuity points is 240.
My caseload has some variety and consists of maternity, post-hospital follow-ups (PHFs), care coordination, and readmission reduction. My favorite cases to work are the high-risk pregnancy members. After over 35 years working in the healthcare field — including working as a certified childbirth instructor, lactation educator, labor, delivery, and postpartum RN — I use my experience to do what I love most; help new mothers. I introduce myself as early as I can during the pregnancy and establish a rapport that goes well beyond the next several months.
While dealing with high-risk pregnancy members, I communicate with:
- Other RN CMs
- Prior Authorization RNs
- Home Health Services
- Medical Equipment Suppliers
- Behavioral Health Services
- Pharmacy techs
- Customer service
- Medical Directors
- All types of unit RNs
I work with young or old moms, repeat moms, and gestation carriers (not planning on being a mom at all). I am never bored with this type of work.
Post-hospital follow-ups (PHFs) are also among my favorite types of calls to make. You never really know what you are going to discover when calling individuals after a recent hospitalization. During each call, I introduce myself and am required to verify member identity.
On a call:
- I verify the member received discharge instructions, their understanding of those instructions, and whether they have any questions.
- I make sure all members are aware of the 24-Hour Registered Nurse (RN) Medical Advice Line and other important phone numbers on their insurance card.
- I assess for any areas of concern for the member or if any warning signs are present and need follow-up.
- I make sure the member has all the necessary prescribed medications.
- I assist with making provider appointments.
- I help members select primary care providers using the in-network provider directory.
- RN CMs never quote benefits, so I refer inquiries such as “Will this be covered?” Or “I got this bill…” to customer service.
- I assist members in getting home health set up or order special equipment.
- I assess the member’s concerns and help accordingly.
Every member contact is an opportunity to screen for any other needed education, services, or support. Educational materials are offered and mailed for free on the top five chronic diseases:
- Coronary Artery Disease or
- Heart Failure
I also provide information regarding:
- End-Stage Renal Disease
- Pain Management
- Rare or Complex Diseases
These types of calls help me build my ongoing caseload or make appropriate referrals to another specialty RN CMs in my department. All calls conclude with a screening questionnaire to assess whether the member has any other needs.
Sometimes a member has been re-admitted to a hospital within 31 days of a previous admission, which automatically enrolls them into a case type called Readmission Reduction. One of the main goals of our department is to help members achieve their highest well-being by providing education, resources, and support. This department also seeks to reduce health care costs for both the member and the insurance company by minimizing risks of unnecessary costly readmissions.
I follow up with these members and providers for four weeks to help re-assess any areas of concern. This regular contact is one way to assure that the member is getting the support they need to improve and stay out of the hospital. I get to know my members and help identify solutions to any ongoing health concerns.
Care Coordination Cases/Calls are more like a screening call. Some of the members on this list have used the emergency department more than once in 30 days. I will attempt to reach the member and address the reasons why they use the emergency room instead of their provider. I make three outreach calls on three different days to contact this member and send a letter to their home address. These calls include helping someone find a primary care provider, secure home services, or getting appropriate medical equipment, or where to find free food banks. I spend a lot of time collaborating between the members and providers, including other departments such as pharmacy and behavioral health.
You now have a glimpse into the life of an RN CM, but in a nutshell, case management is by far the most rewarding and challenging work I have ever done. I use my ears now instead of my eyes. I am a caregiver, a member advocate, and an educator. I am an RN CM for insurance company, and I would not trade it for anything – except retirement.
I encourage all RN’s to explore employment options out there. Resist the initial thought that you would never do a particular type of job, including working for an insurance company doing a telephonic desk job. I never thought I would end up in this type of position. The phone calls I make can be a lifeline to members, and they are pleasantly surprised to find out their insurance offers free support and services. I encourage you to consider this type of work, especially if you need something new and different.
Lorrie Morris has been a front office person, a medical assistant, a certified childbirth instructor, a lactation educator, a doula, a night shift postpartum RN, a triage lead RN, a clinical staff supervisor for midwifery, family practice and internal medicine, and a manager for maternal-fetal medicine and now a certified case manager. She earned her BSN at Aspen University.
Lorrie finds peace in exploring and reenacting historical self-care modalities such as creating a Red Tent in her backyard, growing herbs, and gardening. She is also a proud mother of three grown children; Alyssa, Christopher, and Trinity and enjoys making time for her newest little grandson CJ.