Nurses Are Perfect Candidates for Managed Care Positions

Nurses Are Perfect Candidates for Managed Care Positions

A nurse’s background and expertise makes for a great liaison between doctors and insurance companies.

Experienced nurses who have held traditional nursing roles make excellent candidates for coding, corporate, and managed care positions. They have a clinical understanding of medical procedures, and appreciate how coding and provider documentation complement each other. Let’s explore how a career in managed care is a good fit for nurses.

What Is Managed Care?

Managed care oversees cost and utilization of benefits and ensures plan members are receiving quality healthcare. Third-party managed care organizations (MCOs) are typically contracted by insurance carriers and employ physicians, nurses, coders, and other non-clinical support staff to make determinations on behalf of the insurance carrier. They determine pre-authorizations, benefit management (such as physical therapy needs, pain management utilization, etc.),  and documentation accuracy for reported procedures in claims.

MCOs act as an impartial third party, settling disagreements between the provider’s office and an insurance company by hearing both sides of the story and looking at the presented facts.

Coding is a vital piece of this intricate puzzle. For utilization management (pre-certification and benefits), diagnostic coding is particularly important. The diagnosis code drives the entire procedure: It tells the MCO why the requested procedure is necessary for the patient. Nurses with coding experience are better equipped to make informed decisions on medical necessity.

New Payment Models Change the Equation

Paying providers to keep patients healthy is now more valuable than paying for billed services. The government’s goal is to replace fee-for-service payments with value-based payments that include cost sharing. This is making correct medical coding more important than ever: Under a value-based payment system, codes are not only a billing factor but also a quality factor, used to calculate performance and, ultimately, provider payments.

Giving providers a stake in their patients’ health and rewarding them for taking the best possible care of their patients — keeping them out of the hospital, ensuring they are taking their medications, and performing all preventative services — is what “managed care” is all about.

A Nurse’s Role in Managed Care

The role of a nurse in managed care is unique. Because coding and compliance training is essential, you must wear several hats.

A nurse’s main function in managed care is to act as a liaison between providers’ offices and the affiliated organization. As a managed care nurse, you speak with certain provider groups regarding claims that have “escalated” due to denials. These are usually high cost claims with complex coding. In these circumstances, you pull the cases apart with the medical director who made the initial determinations on the claims. Together, you review the submitted operative reports and the CPT® codes. Your nursing background of anatomy and physiology is put to good use when piecing together these complex puzzles.

Health plans sometimes request written explanations of denials from the MCO to send to the provider’s office. In these cases, generally, the claims are reviewed carefully by the medical director and MCO. A written explanation is crafted, using CPT® descriptions of the code and any citations from the operative report supporting the denial, as well as National Correct Coding Initiative (NCCI) edit references used in determining the denial. These explanations are detailed and comprehensive. This level of explanation may help to educate the provider and/or billing staff as to how the determination was made, and what future coding expectations are for that procedure.

Look to AAPC’s Knowledge Center for articles on clinical documentation improvement such as “7 Deadly Sins of Outpatient Documentation” and “Include MEAT in Your Risk Adjustment Documentation.”

Learn more about AAPC’s medical coding certifications.

Advice for Nurses Looking for a Change

If you are a nurse aspiring to join the business side of healthcare, search for opportunities in your current organization. For example, look to billing staff to explain procedure codes submitted to health plans, volunteer to join your organization’s compliance team, or look for areas of improvement in your providers’ documentation.

Become a Certified Professional Coder (CPC®) and pursue other credentials that spark your interest. Compliance training often compliments a CPC® certification. Becoming certified not only opens opportunities for you, but also tunes you into the intricacies of coding.

I’m glad I took the opportunity to learn the coding and compliance aspects of healthcare, as they have enriched my education and understanding of healthcare. Whatever your role or goal, it’s terrific to keep on learning.


Lisa Tevolini, LPN, CPC, CPCO, is a nurse specialist who began in a multispecialty practice as a nurse for a gastroenterologist. She later became intravenous and infusion certified and performed infusion therapies on patients who received biologics. Within the same practice, she became the nurse case manager and assistant clinical manager. In managed care, Tevolini combines her clinical expertise with the skills she acquired through health plan interactions. She is a member of the Danbury, Conn., local chapter.

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