Why does this question keep disappearing?
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I can see where UM will continue to be necessary to the auth process and the relationship with CMS but as an RN case manager I am not sure if we are as necessary? We provide support, education and work with members to optimize members health, reduce hospitalization and a myriad of other things but if the company is looking to cut costs is anyone truly safe ? We have heard a rumor that the company is deciding if they want to keep case management at all going forward. . We recently have been instructed to participate in “ talk time” with log in to recorded lines so that our work can be monitored throughout the day which seems to support that our work is being more closely scrutinized. We were told we are 99% safe … … why not 100%??!!! Any other thoughts in regards to those of us in more clinical positions?
Yes UMNC were affected and will be doing more auto approval. Do not know how many though.
I agree that frontline UMNCs will likely escape this round but not layoffs in the future. CMS does not require MCG criteria be met for concurrent Medicare cases, but rather go strictly by the two midnight rule, which we have been told by our territory's senior medical director will be the way we determine Medicare cases starting next year due to an audit from CMS. Just Monday they added AssistEdge Playback and Recording to our laptops to look for ways that AI can perform our job. I agree that replacing UMNCs with AI will be a disaster, as all of the AI they have so far makes mistakes every time, but they're chasing the short penny over the long dollar, so they'd rather save the money from paying UMNC salaries to paying for AI and paying unlicenced personnel to clean up behind AI. As far as layoffs for this round go, it's been told to multiple teams that some (4, I believe) UM associate managers and at least one member of senior leadership will be let go this round.
The increase in automation related to UM seems more related to addressing the increase in volume related to membership. Getting back into the affordable care act marketplace increased commercial volume. The goal, I believe, is to keep the UM dept from growing at the rate of new membership. Rather than bloat the dept with additional FTEs that may not be needed in the future, they'd rather find ways to optimize the current workforce -- enter in automation. The automation algorithms are mediocre at best. I've seen many technical oversights in the automated workflow, needing humans to correct mistakes. However, there may be UM role evolution in the future. Maybe care navigation. Perhaps if the company adopts the two midnight Medicare rule automatically, it would decrease caseload. Still, some oversight of decisions will need a clinical component.
Personally i think the UMNCs are at risk but not this round - but soon enough that if we realized how soon we would all jump ship asap and not wait to be axed then have to scramble for a job. That would sc--w the company royally if they lost us before they no longer needed us. I feel like a major change is coming for us - well a lot of us and depending on which department you're in. Notice the increase in automation very recently? I dont think that is a coincidence. It dramatically increased this week
Somewhere on this thread it was reported at least 3 UMNCs and a supervisor were let go… scroll down..
Not the OP, but UMNC = Utilization Manager Nurse Consultant. I think the question keeps disappearing because it's an esoteric role that is an essential component to CMS regulations. CMS requires health plans to use a criteria to make determinations, and the process to arrive at such decisions cannot be arbitrary or capricious. It's likely that it cannot be easily downsized or offshored without directly impacting regulatory compliance related to medical necessity and timeliness. Utilization Management is also one of the few mechanisms the health plan has to maintain fiscal integrity and prevent fraud, waste, and abuse. Attempts to offshore this work has been unsuccessful due to the clinical nature and clinician licensure requirements. There are more barriers, but I'll digress.