Remote Nursing: The Cure to Bedside Burnout

Clinicals is the documentation from Cerner, EPIC, etc sent to the nurse for review.

What is OCR (optical character recognition?  Technology that converts images of typed, handwritten, or printed text—such as scanned documents, photos of documents, or screenshots—into machine-readable and editable text.

Why is it important? You will receive 100 pages worth of clinical/medical records/health records. It is easier to find labs, medications, discharge dates, etc by selecting Ctrl + F and type word (example: WBC, temp, medications) to find what you need instead of scanning each page individually.

Ask the Hiring Manager if clinical has the option to find information using Ctrl + F or OCR. You are better off having this option.

Templates are similar to SOAP (subjective, objective, assessment, plan) notes.   This can include medical history, patients' age, gender, presentation (is the patient/member from home, nursing facility, etc.), medical history, admission date, discharge date, level of care (acute, intermediate, critical), abnormal labs, vital signs, imaging (CT, MRI, X-ray, etc.).

Templates can be used for outbound and inbound phone calls, correcting an admission date, entering a discharge date, etc.

Every insurance plan has a TAT (turnaround time).  It could be 24 hours, 3 days, 4 days etc.  TAT is a deadline the insurance provider has to make a decision to approve or deny an authorization.

Why is TAT important?  If it's 24 hours, everyday you are in a mad dash to either approve that authorization before the TAT ends.  If it is 3 days you will have a 3 day time frame to complete the authorization.  Meaning you approve the authorization or if you can't approve the authorization and have to send it to the doctor to make an executive decision, you want her or him to have time to make a decision before the TAT deadline.

TAT varies by state and insurance plan.  Every state is like its own country. TAT varies by plan.  Each plan has different rules and regulations.  The hiring manager will tell you more about these specifics.

24 Hour Turn Around Time is a mad dash to complete an authorization.

Example: Notification of admission is at 11:12 am, you must complete this authorization by 11:12 am the next day. You complete this authorization by either approving the authorization and sending the approval fax or the MD must complete her/his executive decision.

3 day Turn Around Time is a 3 day time frame to complete an authorization.  You complete this authorization by either approving the authorization and sending the approval fax or the MD must complete her/his executive decision. 3 days is by the end of the business day (before you clock out).

If you are not able to approve an authorization using InterQual or MCG, the next step is to send the authorization to the doctor to make an executive decision.

The doctor will approve or deny the authorization.  In most scenarios this will be an in-house doctor with the company or the doctor will be through an external company such as AMR (American Medical Reviews).

The next steps vary depending on company policy:

A. Another team will submit the approval or denial fax.

B. You will receive a notification to submit the approval or denial fax.

C. You will have to contact the facility to offer a Peer to Peer (P2P) review prior to submitting a request for sending the denial fax.

The Denial and P2P process varies and you may or may not be involved depending on policy and procedures.

The Short Stay Policy differs by insurance plan.  This can be the most confusing policy.  Take plenty of notes, screen shots and ask questions.

Example Scenario 1: Patient is admitted as an Inpatient for "Short Stay" diagnosis.  The Utilization Review Nurse calls the facility to offer the patient to be downgraded to Observation. The facility accepts.  The nurse changes the Inpatient authorization to an Observation authorization and auto approves the authorization.

Example Scenario 2: Patient is admitted as an Inpatient for "Short Stay" diagnosis.  The Utilization Review Nurse calls the facility to offer the patient to be downgraded to Observation.  The facility declines.  The nurse sends the authorization to the doctor for review.

Example Question: What happens if the hospital accepts the Short Stay Policy to downgrade the patient from inpatient to observation, then the patient is upgraded to Inpatient on Day 3 and also discharges on Day 3?

The auditors for some are like the judge, jury and executioner when it comes to scoring your reviews.  They assess several authorizations per month per nurse. Sometimes you pass their audit process and most times you will not.

Rules to pass:

Stick to the Template. If something doesn't apply type: N/A, no documentation received, no clinical or text your employer wants you to use.

Over document aka "spoon feed" information on your Initial Review Template.

Rationale: It is always a good idea to "spoon feed" information.  "Spoon feed" meaning you are over providing information to "paint a complete picture". This will increase your chances of passing your auditors with a 100% grade and to present plenty of evidence when sending an authorization to the doctor for review.

When filling out your initial reviews, be careful using acronyms and abbreviations.

Rationale: Each company has a list of acceptable acronyms. It is easier to spell out the words than to memorize the list of acceptable acronyms.

Besides working in the training environment there  are videos available with "How-to's" such as "How to approve an authorization", "How to discharge an authorization", "How to correct an admission date", "How to create an authorization", etc.

While in training use Snipping Tool or Snagit or Screen Capture to create screenshots of the platform, InterQual, MCG, and other programs and paste to OneNote. Also, type text above or below each screen shot to explain what is being done in that screen shot. This will allow you to use Ctrl+F to navigate directly to that screen shot for guidance.

OneNote allows you organize all notes, templates, links to policies and procedures, and more. This is an amazing resource.

Look for LinkedIn Learning with your employer and search "OneNote"

I prefer hourly.  In my opinion, salary is a fixed income.  As an hourly employee you will have plenty of opportunities for overtime.

Depending on the team your are on, you will automatically have holidays and/or weekends off.   Some teams with 24 hour turn around times offer holidays off when you sign up to have the holiday off.

Ask the Hiring Manager if holidays are automatically off or are off by request and if volunteering to work consists of working a full 8 hours.

Also ask if weekends are optional or rotating.  Example of rotating weekends include being scheduled to work a weekend every 6 weeks.

Most schedules are 8 hour days, 5 days a week.  I have heard of schedules that consist of 10 hour days, 4 times a week, but that shift is very rare.

Positions

LPN/RN

• Concurrent Review (in the hospital - observation, inpatient, adult, pediatric)

• Clinical Reviewer

• Utilization Review

• Utilization Management

• Post Acute (Skilled Nursing Facility, Inpatient Rehabilitation, Long Term Acute Care)

• Prior Authorization (PA)

• Performance Monitor Specialist

• Behavioral Health (BH)

• Case Manager/Care Manager - I suggest you avoid this one due to the high phone call frequency

• Appeals (post denial - last effort to get an authorization approved)

• Trainer-Auditor

• Care Navigator

• Nurse Consultant

Doctor

• Medical Director

• Physician Reviewer

• Physician Advisor

• Telehealth Clinician

• Telemedicine Physician

Business Process Outsourcing (BPO) is the practice of subcontracting specific business operations or processes to third-party vendors.

Believe it or not, you may have co-workers that live in the Philippines. For example, if your see a co-workers name and " - External" appears after her/his name, this may be an outsourced employee.

Always, always, always send a post-interview thank you email.  Send it to the HR interviewer and the the Hiring Manager. The person or person's involved with the interviewing process will be included in the email after you receive notification of the date and time of the virtual interview.
If there is an additional person added to the interview and you don't have their email address, use FirstName.LastName@company.com.  Sometimes this will not work if the interviewer has a hyphenated last name, middle initial added to their email address, or if their first name on zoom is a preferred name over his/her government name.

Search "What is a post interview thank you email" and look for examples and images.

For a list of office necessities, go to the Target Companies digital download.