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Managed care refers to many procedures conducted by a variety of companies to influence the delivery, utilization and quality of medical care in the US. A company need not be totally devoted to a managed care purpose to make some contribution to the system. Some organizations that contribute to managed care, in some way, include national disease organizations, municipal public health departments, private health insurance companies and hospitals. The purpose of any given intervention by an organization can range from cost savings, delivery of care to those most in need or preventing future suffering. Different types of managed care jobs can include careers as varied as a hospital discharge social worker, an insurance company's loss control statistician, or a home health agency supervisor.
Managed care jobs that seek to minimize a health insurance company's exposure to certain types of claims include claims adjusters, utilization review auditors and medical case management nurses. Claims adjusters review claims for potential expenses and factors that may increase medical care and expenses, such as chronic illnesses, lack of social support, mental illness or a history of substance abuse. If he feels the claim requires greater supervision than they can provide by telephone, a claims adjuster can hire a medical case manager to meet personally with the patient and manage his or her recovery. Utilization review auditors are managed care jobs where insurance company employees audit and closely review claims flagged by their computer system as higher than anticipated for the patient's age, sex, disease code or some other factor.
Other managed care jobs seek to maximize a hospital's reimbursement from Medicare, Medicaid or a private health insurance company. For instance, inpatient coders review patient charts to document any additional diagnoses or treatments to add to the final billing. Managed care jobs often present in private and public sectors, utilization review nurses examine the patient records to gain approval from the insurance company claims adjuster for approval of additional inpatient days. In other cases, hospital utilization review nurses work to justify questioned charges with insurance company utilization review auditors.
Some managed care jobs seek to minimize a hospital's losses resulting from Medicare and Medicaid's limits on hospital stay lengths and ceilings for the cost of procedures or treatments. Thus, discharge planners work from a patient's first day in the hospital to plan for his or her discharge as soon as safely possible. Discharge planners work closely with home health care agencies in order to arrange for outpatient nursing care upon discharge from the hospital. The availability of home health care agencies and durable medical equipment (DME) companies often allows a hospital to discharge a patient sooner than would be possible without outpatient supervision.