Managed Care Nursing

Managed care nurses are slightly unique, in that instead of working directly with patients, they work on the business aspects of healthcare. They use their nursing experience and medical knowledge to work with healthcare providers, insurance companies, managed care organization, and HMOs, striving to facilitate patient care in the most cost-efficient manner possible, while also focusing on quality patient care and patient satisfaction. Their job is to weigh the fiscal cost of medical choices as well as weighing the health risks and benefits that are likely to accompany those choices. They must be familiar with Medicare, Medicaid, and other healthcare systems, and have knowledge of insurance compensation in healthcare. Interacting with physicians, patients and their families, and medical bill payors is part of the job, and managed care nurses must have good analytical and data management skills. Their work serves all healthcare patients, but will often primarily focus on the poor and the elderly, as they are often recipients of government health benefits like Medicare and Medicaid.

If you are interested in becoming a managed care nurse, you will have to first become a registered nurse if you are not already. In just two years, you can earn your associate degree of science in nursing (ASN), which you can also use as a step toward your bachelor’s degree through an RN to BSN program. If you choose to go to a four-year college or university, you can earn a bachelor of science in nursing, which often times will make you more competitive when seeking a managed care nurse job. Earning a nursing diploma from a participating hospital nursing program is also an option, although this is frequently seen as less competitive and is now less common with the growth of associate programs. If you already have a non-nursing bachelor’s degree, you can pursue an accelerated bsn degree program for those with non-nursing degrees, and this requires just one to two years. All of these degrees will involve clinical and hospital training and classroom study in subjects such as anatomy, chemistry, pharmacology, and microbiology. Once you graduate from an accredited nursing program, the final step is to pass the state’s board of nursing licensing exam, which is called NCLEX (national council licensure examination). Passing the NCLEX is the final licensing step in most states to become a licensed registered nurse (RN). There is also opportunity for nurses to become nurse practitioners in managed care. The additional education at the master’s or doctoral level can help them assume a higher degree of responsibility and a more important role in forging new, more efficient health care systems.

Managed care nurses who undertake voluntary certification will be able to use the title Certified Managed Care Nurse (CMCN) as a way to demonstrate their commitment to excellence and knowledge in managed care nursing specialty. Managed care nursing certification is not required, but it proves to those you are caring for and to other medical professionals who you work with that you are qualified according to national standards of care. Eligibility requirements for managed care nursing certification consist of taking study courses, such as curriculum from the American Association of Managed Care Nurses, or from a similar and equivalent institution. Certified managed care nurse certification must be renewed every three years. With a master’s degree in leadership and management or additional work experience or education in case management, such as a nursing case management certificate, you can also sit for the more advanced case management certification exam, with the opportunity to become a certified case manager (CCM).

Managed care nursing is certain to grow, as the health care industry expands and is constantly looking to balance the need for high quality patient care and more cost efficient spending in health care. If combining nursing with a career in managed care interests you, get started on the path to managed care nursing now by researching nursing degrees that address your current educational and professional levels. You’ll find CCNE and NLNAC approved schools and programs throughout the site that will help you meet your personal and professional goals.

(Sources: American Association of Managed Care Nurses, The American Board of Managed Care Nursing, Cohen SS, Juszczak L. – Journal of Pediatric Health Care, 1997 Jan-Feb;11(1):3-11 “Promoting the nurse practitioner role in managed care”, Center for Case Management, BLS)