A Policy of Caring

Magda Pascal recalls the 37-year-old man who lay close to death in the hospital after suffering massive burns in a work accident. His injuries were so severe that both arms had to be amputated, and he remained in intensive care for more than three months. During those first several weeks, his family often wondered if he would live.

Yet Pascal smiles when she thinks of this man. The last time she saw him, he was living at home again and had mastered the use of his artificial arms. He could dress and feed himself and had learned to fish again with a modified fishing rod. He could drive and do volunteer work, and he was even thinking about playing a little baseball.

“That’s what keeps me working,” she says.

Pascal, RN, MPA, CRRN, CCM, CSDA, became acquainted with this patient in her role as a case manager working in the insurance industry. Her company, Quantum Resource Management International in Fort Lauderdale, Fla., provides case management services for insurance firms and third-party health care administrators. In the case of the burn victim, she worked with doctors, nurses, the family and the insurance company to make sure the patient received appropriate care from the time he entered the hospital until he went home from rehabilitation.

This is just one example of the wide variety of interesting career alternatives nurses can find in the insurance industry. Yet many nurses know very little about these opportunities, and the role nurses play in this arena is often misunderstood.

“Some people think that all nurses in the insurance industry do is deny payment of claims,” says Donna Cardillo, RN, a nationally known career consultant and president of Cardillo & Associates, which produces professional development seminars for nurses.

In reality, working in the insurance industry can provide nurses with rewarding opportunities to advocate for patients and for quality health care in general. For example, nurses can develop preventive education programs for health insurance plans, oversee the care of chronically ill or severely injured patients, provide technical assistance to improve quality of care, conduct utilization reviews to make sure the care being provided is appropriate and even give medical advice to patients over the telephone.

Minority nurses have an important role to play in the insurance industry, because the diverse perspectives they bring to the table can lead to greater cultural sensitivity within a majority-dominated and often impersonal health care system. For instance, Pascal, who moved to the United States at 19 from her native Mexico, works with many patients who speak only Spanish or very limited English. The fact that she can communicate with them without an interpreter helps establish rapport and remove barriers to care, she says.

“Colleagues from different ethnic backgrounds can help one another understand various cultures to serve patients better,” agrees Chris Valdivieso, RN, BSN, CSM, an African-American nurse who heads her own insurance case management firm.

What’s Your QIO?

Nurses have always worked in the insurance industry, but today there are more job opportunities than ever before, according to Cardillo, author of Your First Year as a Nurse (Prima Publishing). Starting salaries for entry-level positions range from $35,000 to $55,000, she adds. Experienced nurses in supervisory positions can make $60,000 a year and more, while nurses in administrative roles can earn six-figure salaries. While some insurance companies employ LVNs for certain entry-level jobs, many positions require nurses to be RNs, and a master’s degree is usually necessary for top administrative jobs.

Cardillo, who once worked as a health services manager and a quality improvement and pre-certification coordinator for an HMO, says her experience in the insurance field gave her a much broader understanding of what’s involved in health care. “You see the other side of providing care,” she explains. “You see the costs. It’s a very eye-opening experience.”

Career opportunities are available in both the private and public sector. For example, nurses can work for health insurance companies–including HMOs, managed care plans and workers’ compensation insurers–in such areas as quality improvement (QI), utilization review (UR) and case management.

Medicare Quality Improvement Organizations ¬(QIOs)–also known as Peer Review Organizations (PROs)–are a great place to start and get experience, Cardillo notes. Every state has a QIO, and each of these agencies works under contract to the federal Centers for Medicare and Medicaid Services at the U.S. Department of Health and Human Services in Washington.

QIOs work with doctors, hospitals and other care providers to help make sure Medicare beneficiaries get appropriate, effective care at the right time. In addition to monitoring quality and delivery of care, QIOs also provide patient education on disease prevention and work with private employers to help them choose high-quality health plans and health care providers.

QIOs are typically involved with several major ongoing efforts, many of which relate directly to the national focus on reducing racial and ethnic disparities in health. Every state QIO, for instance, must work to improve care in six clinical areas, including heart attack, stroke, congestive heart failure, pneumonia, diabetes and breast cancer–all of which have been identified as serious health risks for Americans of color. (See “A PROactive Approach to Reducing Health Disparities.”)

In addition, Medicare health plans are required to complete quality improvement studies and reports on two clinical areas each year. The federal government selects one of the areas to be studied and the health plans choose an additional area on which to focus attention.

Saleema Hashwani, RN, MS, is a project manager for M+CQRO (Medicare + Choice Quality Review Organization) in the Community Based Quality Improvement department at CMRI, a QIO based in San Francisco. This year’s federal clinical area for quality improvement is breast cancer screening. Hashwani verifies the evidence-based information submitted by the health plans and coordinates teams of doctors and analysts that review the data and make recommendations. She then forwards the reports to the federal government and provides technical support to regional Medicare offices.

Hashwani had worked as a community health nurse in Pakistan before moving to the U.S. two years ago to pursue a master’s degree at the University of California, San Francisco. She started working for CMRI as part of an internship during her studies and later accepted a permanent job there. Now, besides working at the QIO, she is earning a doctoral degree in nursing at UCSF, focusing on health issues affecting immigrant Pakistani working women in the Bay Area.

Hashwani says she enjoys her insurance industry career because it provides exposure to evidence-based projects focused on preventive medicine. The work is stimulating and challenging. “Every day, I encounter something new,” she asserts. Nurses interested in working for a QIO should be able to meet deadlines, be interested in preventive health care from a system-level perspective and have the flexibility to adapt to change, Hashwani adds.

Today, many nurses are making an impact through QIOs. Hashwani and a colleague recently conducted a survey and found that more than 1,000 nurses nationwide are working for these state agencies–many of them in leadership positions, including seven nurses who are chief executives.


On the Case

Case management is another career that can offer many opportunities for nursing professionals, especially veteran bedside nurses who are interested in career alternatives beyond the hospital setting. Case managers, who oversee the care of patients with chronic illnesses or severe injuries, can work as employees of insurance companies or independently as private contractors.

Pascal, who had worked in community health and home health care management, was looking for a career change 11 years ago when a friend recruited her to work in case management. Pascal joined the staff of a small, Florida-based insurance company, then started her own independent practice seven years ago. Insurance companies and health care plan administrators hire her to oversee the care of seriously injured workers and older patients with complex health problems, such as cancer.

After Pascal is assigned a case, she gathers information from the insurance carrier about the patient, talks to the treating doctors, reviews health records, meets with family members and, if possible, speaks with the patient. (In cases of severe injuries, the patient may be unconscious.) She keeps in close touch with everyone involved, follows the patient’s medical status, prognosis and treatment plan, and helps coordinate it all.

Even after the patient leaves the hospital, Pascal continues in her coordinator role to ensure continuity of care. Meanwhile, she keeps the insurance carrier informed every step of the way and helps facilitate approval for all the appropriate expenditures.

Pascal says she enjoys her work as an independent consultant because it allows her to maintain her own philosophy of how care should be delivered. Although she develops close relationships with her patients, she strives not to let them and their families become overly dependent on her. “I have to remind myself that one day, if I do my job correctly, they will be on their own,” she comments.

Superb communication skills are a must for case managers because they have to explain complex issues and keep many different stakeholders informed during a time of crisis. They must also be skilled critical thinkers and problem solvers and be able to advocate for all stakeholders, not just for patients, adds Valdivieso, president and founder of the case management firm CCMA, Inc.

Furthermore, she continues, case managers can’t recommend treatment alternatives solely on the grounds that they are the least expensive for the insurance companies. Sometimes greater costs in the short run can pay off in big savings and better health for the patient in the long run. The process requires an ability to understand all the intertwining complex issues.

Valdivieso is another career-changer who had worked in a hospital operating room and as a home health care nurse when she became intrigued by the work of the case managers she met. Like Pascal, she got into the field by working for an insurance company and then launched her own business.

Valdivieso says she loves the process of working with families to coordinate treatment and services so they can get the best health care at costs they can afford. Recently, she has begun to focus her case management expertise in a new direction: providing consulting services for people who need help in coordinating health care for their aging loved ones. In this new line of her business, she works for private paying clients rather than insurance companies but uses many of the same skills.


Can We Sell You an Insurance Career?

For minority nurses, insurance industry nursing can be an exciting and empowering career that offers the best of two worlds–the opportunity to advance into management and entrepreneurial roles while still working closely with patients and their families to ensure effective, culturally competent care. So what’s the best way to get started in this field?

Cardillo recommends joining insurance industry professional organizations and taking advantage of the networking opportunities they provide. This is a great way to find contacts who know of job openings, as well as people who can provide general information about the field. Some of these associations have online bulletin boards and chat rooms where professionals can exchange information. And, of course, you can also contact insurance companies and QIOs directly to ask about job opportunities.

Working in the insurance industry may not be for everybody, though. Cardillo suggests that nurses explore the field thoroughly, talk to many people in the industry and visit job sites to get a feel for the work environments. Some jobs, for instance, may involve working 9 to 5 in big offices with rows of cubicles. While some nurses may find this a welcome change from working 12-hour hospital shifts, others may miss the intensity and familiarity of working in a clinical setting.

Pascal suggests that nurses interested in case management learn about the nursing specialties involved and what is required to become certified in them. One way to get this information is through organizations such as the Association of Rehabilitation Nurses and the International Association of Rehabilitation Professionals. She also offers these three tips: Find mentors, network with other case managers and search the Internet for job opportunities and more information.

Exploring Insurance Industry Nursing Careers Online

Here are some helpful Web sites for finding more information about careers in insurance industry nursing, including case management, quality improvement and more:

• Cardillo & Associates Professional Development Seminars, www.dcardillo.com. Career consultant Donna Cardillo, RN, offers seminars, tapes and articles about career alternatives for nurses, including opportunities in the insurance industry.

• The American Association of Managed Care Nurses, www.aamcn.org. This site contains good background information and news about managed care nursing, an online discussion group and information about jobs and educational opportunities–including a Certification in Managed Care Nursing home study program.

• The Case Management Society of America, www.cmsa.org. CMSA’s site offers a variety of news and resources, including Special Interest Group forums, “virtual seminars” and online continuing education units.

• The American Health Quality Association, www.ahqa.org,

represents Medicare Quality Improvement Organizations (QIOs). The Web site includes a listing of all QIOs nationwide, a job board, an events calendar, legislative updates and a wealth of information about the role of QIOs in health care.

• The Association of Rehabilitation Nurses, www.rehabnurse.org, and The International Association of Rehabilitation Professionals, www.rehabpro.org. For nurses interested in providing case management services for persons with disabilities, serious injuries and chronic illnesses, these two sites are a good introduction to the field.

A PROactive Approach to Reducing Health Disparities

Just because a nurse works in the insurance industry doesn’t mean that he or she can’t be directly involved in helping to eliminate racial and ethnic health disparities. Many Medicare Quality Improvement Organizations (QIOs)–also known as PROs (Peer Review Organizations)–around the country are playing a key role in developing community-based prevention, screening and treatment programs to improve the health of minority Medicare beneficiaries.

Here are just a few examples from the American Health Quality Association (www.ahqa.org), the organization that represents PROs:

• CMRI, a leading California QIO, launched a campaign to develop long-term, effective solutions to low influenza immunization rates among African-American seniors in Alameda and Los Angeles Counties.

• In another recent initiative, CMRI collaborated with the API Task Force of Partnered for Progress, Pacific Asian Language Services, and the National Asian Pacific Center on Aging to develop culturally competent educational materials about mammography targeted to Asian/Pacific Islander women who suffer high rates of breast cancer.

• The South Dakota Foundation for Medical Care, a QIO in Sioux Falls, partnered with physicians, residents, the University of South Dakota School of Medicine and the Indian Health Service on a program to educate health care providers about the benefits of annual screening for microalbuminuria and the use of ACE inhibitors to delay development and/or progression of diabetic kidney disease. Among the 179 doctors and 40 clinics that participated, the percentage of patients tested increased more than five-fold, from 9% to 50%.

• The Arkansas Foundation for Medical Care in Little Rock held a series of health fairs in counties with the lowest rates of mammography among African-American women. The health fairs were held in partnership with the Witness Project, a church-based breast and cervical cancer education/prevention program targeted to low-income, rural black women.