Managed care refers to a number of procedures carried out by a number of companies in order to influence the delivery, utilization, and quality of medical care in the United States. To contribute to the system, a company does not have to be entirely dedicated to managed care. National disease organizations, municipal public health departments, private health insurance companies, and hospitals are some of the organizations that contribute to managed care in some way. The goal of any given organization intervention can be anything from cost savings to providing care to those who are most in need to preventing future suffering. A hospital discharge social worker, a loss control statistician for an insurance company, or a home health agency supervisor are all examples of managed care jobs.
Claims adjusters, utilization review auditors, and medical case management nurses are examples of managed care jobs that aim to reduce a health insurance company’s exposure to certain types of claims. Claims adjusters examine claims for potential expenses and factors such as chronic illnesses, a lack of social support, mental illness, or a history of substance abuse that may increase medical care and expenses, such as chronic illnesses, a lack of social support, mental illness, or a history of substance abuse. A claims adjuster can hire a medical case manager to meet with the patient and manage his or her recovery if he believes the claim requires more supervision than they can provide over the phone. Insurance company employees who work as utilization review auditors audit and closely review claims flagged by their computer system as higher than expected for the patient’s age, sex, disease code, or some other factor.
Other managed care jobs aim to increase a hospital’s Medicare, Medicaid, or private health insurance reimbursement. Inpatient coders, for example, review patient charts for any additional diagnoses or treatments that should be included in the final billing. Utilization review nurses examine patient records to obtain approval from the insurance company claims adjuster for additional inpatient days in managed care jobs, which are common in both the private and public sectors. In other cases, hospital utilization review nurses work with insurance company utilization review auditors to justify disputed charges.
Some managed care positions aim to reduce a hospital’s losses as a result of Medicare and Medicaid’s restrictions on hospital stay lengths and cost ceilings for procedures and treatments. As a result, discharge planners begin working with a patient on the first day of his or her stay in the hospital to plan for his or her safe discharge as soon as possible. Discharge planners collaborate with home health agencies to arrange for outpatient nursing care after a patient leaves the hospital. Because of the availability of home health care agencies and durable medical equipment (DME) companies, hospitals are able to discharge patients sooner than they would be able to without outpatient supervision.