A managed care nurse is a nursing professional with specialized knowledge of managed care systems and the medical professionals and patients that rely on them. Managed care nurses play an integral role in ensuring that these systems run smoothly.
What Is a Managed Care Nurse?
Managed care is a type of health care system in which patients select a group of medical professionals responsible for their health care. Some examples of managed care health insurance plans include Health Maintenance Organizations (HMOs) and Preferred Provider Plans (PPO’s), and government-funded healthcare assistance programs. These managed care plans focus on preventive health care to keep costs down and often offer incentives to physicians and healthcare facilities that participate in these plans.
As a managed care nurse, you will work directly with patients, physicians, nurses, medical facilities, insurance companies, and government agencies. You will frequently act as a liaison and educator, ensuring that patients receive high-quality health care when they need it. It will also be your responsibility to advocate for treatment plans that are appropriate and cost-effective.
You will work with patients of all types, including the young and old, who may need different medical care types. Oftentimes, you may find yourself working with low-income individuals and families that rely on government-funded healthcare programs, such as Medicare and Medicaid.
A managed care nursing career has many advantages over some other nursing careers. For instance, you will often work regular hours and a somewhat chaos-free work environment. However, you will also spend more time completing paperwork rather than directly caring for patients.
What Do Managed Care Nurses Do?
One of the main responsibilities of a managed care nurse is to keep healthcare costs down for both patients and insurance companies. To achieve this, these nursing professionals focus on making sure that patients aren’t undergoing unnecessary medical procedures and encouraging patients to seek preventive medical care.
Unnecessary medical procedures can drive the cost of healthcare through the roof. Managed care nurses work with doctors and patients to ensure that patients are not undergoing expensive medical procedures that they don’t need. This may involve interviewing physicians and examining patient medical records.
In the long run, preventive medical procedures cost much less than major medical procedures patients may need when they get ill. Therefore, managed care nurses will often work to ensure patients seek the proper preventive procedures they need. These procedures may include regular checkups, health screenings, vaccinations, and immunizations. Managed care nurses often counsel and educate patients on the importance of these procedures, which keep overall medical costs down and help prevent major illnesses or catch them early.
Ensuring quality care for patients in a managed care setting is another important aspect of being a managed care nurse. These nursing professionals work to ensure each patient gets the care they need and may even work to find ways to improve the overall quality of care in a medical facility.
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Where Do Managed Care Nurses Work?
Generally, managed care nurses work in office settings rather than in clinical settings. They are often employed by clinics, hospitals, community health centers, and insurance companies. Some government agencies and social service programs may also hire managed care nurses.
How to Become a Managed Care Nurse
To become a managed care nurse, you will first need to become a registered nurse. To do this, you will need to earn your nursing diploma or degree and pass the National Council Licensure Examination for Registered Nurses (NCLEX-RN). Once you’re licensed, you can then start gaining experience in a clinical setting.
The American Association of Managed Care Nurses (AAMCN) offers certification for managed care nurses. To sit for the certification examination, you must have a valid license as a registered nurse and three to five years of experience in a clinical setting. You must then complete a home study program in managed care nursing that covers four important areas: an overview of managed care, healthcare economics, healthcare management, and patient issues.
You may be able to skip the home study program if you can provide evidence of experience or education that is equivalent to the program coursework.
