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.

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.

They are 100% remote. Correct. Best use is to keep the nurses and up the case load.

The healthcare systems that are really greedy will outsource the job to a different state or nation. Fortunately I think those are in the minority. None I’ve heard of in CA

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.

Its not those types of nurses. Its utilization review nurses and honestly every nurse in this related field knew this was likely to happen and aren’t in disagreement with it. Bedside nurses (which hold greater power than other nursing in unions) have no idea what some other fields of nursing do.

Its actually good use of “AI”

How this position works is that you had nurses manually scanning and scouring different parts of the chart, manually typing down some of those findings, clicking check boxes anyways for medical necessity. Honestly, it was annoying and very administrative in nature. It took 20-25 minutes on average to do a review 10 years ago with most of it just reviewing the chart to put in your notes and check off boxes.

Technology has improved with navigators to more easily find the information so it quickened the time over the years to find the information. But I also knew this position was going to be the first place most places were going to implement AI. Why? Its honestly just pulling information. So whats going to end up happening in this field is that you’re going to need less nurses to do the same volume. Its honestly better use of this sort of nurse. Have them manage more cases and audit the information being pulled by whatever AI tech is being used (If it’s Interqual Autoreview, this technology dates back to 2018 and is tested). Because thats all they are doing anyways. It’s a medical audit. They do help more patients this way but the union won’t tell you that and disappointed that the Guardian didn’t explain the finer details.

I’ve been telling people this is going to happen for years and most people in this specific nursing field are not opposed to it because they all use it anyways already (at least in CA). You’re either using Milliman or Interqual for the job. There are no other software to use lol

Sorry this is long. Just frustrating article to read.