Managed Care Nurse

What Is a Managed Care Nurse?

Nurses who specialize in managed care act as consultants between patients, healthcare providers, insurance companies, and government agencies, ensuring that patients receive high-quality, cost-effective treatment. Managed care nurses are experts in the managed care system, which includes Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), and government-funded healthcare assistance programs such as Medicare and Medicaid. Managed care nurses assess a patient’s healthcare needs and connect them to cost-effective providers. They also counsel patients on the significance of preventative care and aim to keep costs down for both patients and insurance companies.

Becoming a Nurse in Managed Care

If you’re interested in becoming a managed care nurse, students must first get an Associate’s Degree in Nursing or a Bachelor’s Degree in Nursing and pass the NCLEX-RN examination. Nurses who work in managed care typically begin their careers as staff nurses in clinics or private practices. Others began their careers as RNs with a background in social work or social services. RNs interested in specializing in managed care nursing may also pursue the American Board of Managed Care Nursing’s Certification in Managed Care Nursing credential.

A typical job advertisement for a managed care nursing position would likely include the following credentials, in addition to others that are institution- and patient-specific:

  • ADN or BSN degree and a valid RN license
  • Certification in Managed Care Nursing is an added advantage.
  • Working knowledge of managed care systems

On a daily basis, you will need strong interpersonal and communication skills to coordinate with patients, healthcare providers, insurance companies, and government organizations.

Computer expertise is necessary for entering patient health assessments, maintaining records, and completing required insurance forms.

What Education Do Managed Care Nurses Need?

Managed care nursing positions need an ADN or BSN in addition to an active RN licensure. Elective courses in social work during the nursing school are particularly beneficial for a future in managed care nursing, as the majority of managed care nurses work with patients who rely on social services to pay for their healthcare. In general, advanced degrees are not required, although some managed care nurses may choose to earn a Master’s of Science in Nursing in order to proceed into nursing management or leadership.

Is it necessary to obtain any certifications or credentials?

While certification in managed care nursing is not always required to get the position, earning the Certification in Managed Care Nursing credential administered by the American Board of Managed Care Nursing provides managed care nurses seeking employment with a distinct competitive advantage.

Where Do Nurses in Managed Care Work?

Nurses who specialize in managed care frequently work for health maintenance organizations (HMOs), preferred provider organizations (PPOs), or for government agencies and social service programs. Additionally, they may work in the following fields:

  • Hospitals Clinics
  • Specialty clinics
  • Centers for community health

What Is the Role of a Managed Care Nurse?

Nurses who specialize in managed care use their specialist understanding of the managed healthcare system to connect patients with cost-effective healthcare providers who can offer the necessary quality of care. Managed care nurses teach patients on the value of preventative healthcare, such as routine check-ups and vaccines, as well as proper nutrition and exercise, which can help both patients and insurance companies save money in the long run. Frequently working with the elderly and low-income individuals who rely on government assistance such as Medicare and Medicaid for healthcare, managed care nurses serve as a liaison between patients, healthcare providers, hospitals, and insurance companies to ensure patients have consistent access to high-quality medical care.

What Are the Responsibilities and Responsibilities of a Managed Care Nurse?

  • Assist healthcare professionals, nursing homes, hospitals, patients, and insurance companies in ensuring consistent and cost-effective care.
  • Evaluate the patient’s treatment plan and give recommendations for cost-effective care alternatives that will improve the patient’s quality of life.
  • Patients and caregivers should be educated about preventative healthcare, such as routine medical visits and vaccines, as well as illness management.
  • Assess patients’ physical, psychological, and emotional well-being to ensure they receive timely interventions and high-quality care.

Salary and Employment for Managed Care Nurses

Nurse supervisors in managed care can earn a median pay of approximately $70,545, with a range of $64,000 – $88,322. The US Bureau of Labor Statistics projects that employment of registered nurses will expand by 16% from 2014 to 2024. The prognosis for managed care nurses is also expected to improve as the population ages and more people rely on managed care plans such as Medicare.