Its a lot of data pull. Nurses are still there to audit which is their job. The clinical part is knowing the data, ensuring its there and telling the doctors if the patient doesn’t meet medical necessity by the insurance companies and what’s needed if they want their patient to be covered for services. Its the doctors making the changes not the nurses. Our healthcare system does this via chat BTW.
There’s not a lot of communication. I did it for at least two healthcare systems 10 years ago including Kaiser and still work with individuals at my healthcare system in this specific position. They just got more cases since its so much faster and simpler to do their job. And honestly, they’re helping more patients.
I know what you mean by it doesn’t seem like a checkbox sort of thing but it doesn’t change the fact that checkboxes are how they’ve been doing it for decades.
I already see some down votes but I really don’t care. Just thought I would provide some education on what this work really entails as I see in the comments that many people are thinking bedside nurses are being replaced which is definitely not the case.
I think the fact it’s a checkbox is irrelevant here. From what I understand, these yes/no questions have very real consequences for the patients they’re about. If entering the wrong thing can have negative consequences, an AI shouldn’t be filling that out. Not to mention, if the data in the medical file is wrong, a nurse who’s actually spoken with the patient will actually have opportunities to correct things that an AI will never see.
Of course. From the practices I’ve seen and learned from national conferences its never 100% AI. There’s still a nurse that is reviewing and a physician as well when needed.
Also not sure about Milliman, but for the InterQual Autoreview the accuracy is there. Its been out and in use since 2018. If it wasnt all the UM nurses would be griping. They are not people that are afraid of advocating for themselves. No way they’re not reviewing/auditing unless they want their license to be at risk. It’s more like an advanced algorithm that pulls from the epic EHR system. Labs values, icd 10 codes, iv antibiotics, vitals are some examples of things i would imagine it can pull with high reliability. Normally 1 day retrospective but to your point, if something is missing, can notify the attending Dr. Utilization review team is looking back at charts retrospectively and sending interventions and findings to insurance to get patients covered. And if something is missing, they will let the drs know and the Dr can ensure they add the nebulizer or whatever patient was missing going forward.
The charting documentation is a different thing.
Re: Her job. Sucks. There will be less nurses needed to do the same amount of work with technology. All of us knew this. I think the best thing to do as a UM nurse is continue what they’re doing, be a high performer and keep up. If you don’t keep up, 100% you’re going to go first. The quotas sucked while I was working in this position. I kept up. But mostly didn’t stay as it wasn’t for me. Felt very monotonous and missing direct patient interaction. Def important but unfortunate position needed as result of our dysfunctional healthcare system. Its bittersweet.
For what it’s worth, I’m not downvoting you. My server doesn’t allow downvotes so I can’t even see them.
I just want to make sure we’re doing better for people, not worse. Based off the quote it seemed like a bad idea, but I can also understand just being mad at AI taking over your job. I hope you’re right and that this improves outcomes and decreases admin time. Healthcare is so important and is in a disastrous state in the US. I just want everyone to be well.
Same! I think we just have to look at every proposal and every change and go from there.
The healthcare system is terrible and there’s so much chaos and dysfunction unfortunately. I find the need of these UM nurses and this specific nursing very bittersweet honestly. We get paid well and job security but our jobs came from so many people needing help to navigate the healthcare system. It can be rewarding getting what the patient needs but it shouldn’t be this difficult. There are also times we’re limited or restricted by the system… And we just work with what we can do. Its an interesting position to be in.
This is a very different type of nursing.
Its a lot of data pull. Nurses are still there to audit which is their job. The clinical part is knowing the data, ensuring its there and telling the doctors if the patient doesn’t meet medical necessity by the insurance companies and what’s needed if they want their patient to be covered for services. Its the doctors making the changes not the nurses. Our healthcare system does this via chat BTW.
There’s not a lot of communication. I did it for at least two healthcare systems 10 years ago including Kaiser and still work with individuals at my healthcare system in this specific position. They just got more cases since its so much faster and simpler to do their job. And honestly, they’re helping more patients.
I know what you mean by it doesn’t seem like a checkbox sort of thing but it doesn’t change the fact that checkboxes are how they’ve been doing it for decades.
I just did a simple YouTube search example of checkboxes at 720 min mark and 10 min. That’s what its always looked like. You have nurses checking those boxes to send to insurance.
I already see some down votes but I really don’t care. Just thought I would provide some education on what this work really entails as I see in the comments that many people are thinking bedside nurses are being replaced which is definitely not the case.
I think the fact it’s a checkbox is irrelevant here. From what I understand, these yes/no questions have very real consequences for the patients they’re about. If entering the wrong thing can have negative consequences, an AI shouldn’t be filling that out. Not to mention, if the data in the medical file is wrong, a nurse who’s actually spoken with the patient will actually have opportunities to correct things that an AI will never see.
Of course. From the practices I’ve seen and learned from national conferences its never 100% AI. There’s still a nurse that is reviewing and a physician as well when needed.
Also not sure about Milliman, but for the InterQual Autoreview the accuracy is there. Its been out and in use since 2018. If it wasnt all the UM nurses would be griping. They are not people that are afraid of advocating for themselves. No way they’re not reviewing/auditing unless they want their license to be at risk. It’s more like an advanced algorithm that pulls from the epic EHR system. Labs values, icd 10 codes, iv antibiotics, vitals are some examples of things i would imagine it can pull with high reliability. Normally 1 day retrospective but to your point, if something is missing, can notify the attending Dr. Utilization review team is looking back at charts retrospectively and sending interventions and findings to insurance to get patients covered. And if something is missing, they will let the drs know and the Dr can ensure they add the nebulizer or whatever patient was missing going forward.
The charting documentation is a different thing.
Re: Her job. Sucks. There will be less nurses needed to do the same amount of work with technology. All of us knew this. I think the best thing to do as a UM nurse is continue what they’re doing, be a high performer and keep up. If you don’t keep up, 100% you’re going to go first. The quotas sucked while I was working in this position. I kept up. But mostly didn’t stay as it wasn’t for me. Felt very monotonous and missing direct patient interaction. Def important but unfortunate position needed as result of our dysfunctional healthcare system. Its bittersweet.
I appreciate the information.
For what it’s worth, I’m not downvoting you. My server doesn’t allow downvotes so I can’t even see them.
I just want to make sure we’re doing better for people, not worse. Based off the quote it seemed like a bad idea, but I can also understand just being mad at AI taking over your job. I hope you’re right and that this improves outcomes and decreases admin time. Healthcare is so important and is in a disastrous state in the US. I just want everyone to be well.
Same! I think we just have to look at every proposal and every change and go from there.
The healthcare system is terrible and there’s so much chaos and dysfunction unfortunately. I find the need of these UM nurses and this specific nursing very bittersweet honestly. We get paid well and job security but our jobs came from so many people needing help to navigate the healthcare system. It can be rewarding getting what the patient needs but it shouldn’t be this difficult. There are also times we’re limited or restricted by the system… And we just work with what we can do. Its an interesting position to be in.