Managed care nurses work to provide quality, cost-effective care to patient populations enrolled in a managed care plan, like an HMO, PPO, or Medicaid. Through managed care plans, healthcare delivery is focused on cost savings while maintaining quality of care. This distinction requires experienced healthcare providers to discern needed tests, procedures, and all aspects of healthcare delivery.
Some managed care nurses may work primarily with older adults, others with children. Still, other roles may require management of patients of all ages. Managed care nurses often work normal business hours and rarely see patients in person. However, their work paves the way for patients to get precisely what they need to stay well.
Where Do Managed Care Nurses Work?
Since managed care nurses don’t work with patients directly, they mostly work away from patient units. While they can work in hospitals, you will usually find them in the administration wing. They may also work in:
Community health centers
Government agencies
Health management organizations (HMOs)
Medicaid and Medicare
Preferred provider plans (PPOs)
Social services programs
Specialty clinics
Telephone triage centers
In community health centers, managed care nurses may work with people from a lower socioeconomic background. These roles offer nurses a chance to ensure marginalized groups receive the healthcare they need.
Managed care nurses who work directly for health management organizations and preferred provider plans are able to act as a liaison between payors, healthcare providers, and patients. Approving or denying care can be a fine line, and nurses make excellent mediators in these negotiations.
A managed care nurse may work in a specialty clinic or a telephone triage center as a reference person for those answering the phones. As telephone triage nurses walk patients through their next steps, managed care nurses can advise patients on what tests and treatments will be covered.
What Does a Managed Care Nurse Do?
Managed care nurses have two priorities: to keep healthcare costs at a minimum and to provide quality healthcare to their patients. Sometimes these two goals can feel at odds, and managed care nurses can offer an experienced eye for what kinds of tests and procedures may or may not be necessary.
Unnecessary medical procedures come at a cost for patients, too: both financially and otherwise. For example, if a young woman gets an unnecessary litany of exams, tests, and biopsies as a precaution after an inconclusive mammogram, she will be forced through the financial cost of all these tests and weeks of anxiety waiting for results.
On the flip side, managed care nurses also push for these tests and procedures when they are truly needed. Nurses in this role work closely with both healthcare providers and patients and try to keep everyone on the same page. To assist in these decisions, managed care nurses often get to know a patient’s medical record backward and forward. They may also need to interview physicians and get regular updates on a patient’s plan of care.
One proven way to prevent healthcare overspending is to encourage preventative medical care. Managed care nurses spend a lot of time educating patients on the importance of screenings, regular checkups, and immunizations.
How Do I Become a Managed Care Nurse?
Aspiring managed care nurses must first graduate from an accredited nursing program. Managed care nurses can graduate with an Associate Degree in Nursing (ADN) or a Bachelor of Science in Nursing (BSN). An ADN typically takes two years to complete, while a BSN may take four. However, both programs often offer accelerated options, in which a degree may be earned in as little as a year.
After graduating with their degree, nurses can apply for nursing jobs as graduate nurses (GNs). Many managed care roles require RNs to have some patient-facing experience before they can apply, and many nursing units offer well-rounded experience. Nurses can begin their training as GNs while they prepare to take their state licensing exam, the NCLEX-RN. After GNs pass this standardized test, they become RNs. Once they complete their facility’s orientation period under a nurse preceptor, they can work independently.
Once nurses have a good grasp on how the healthcare system works, have cared for patients themselves, and understand their needs, they may be ready for a managed care role. Any nurse can pursue a specialty certification. The American Association of Managed Care Nurses (AAMCN) offers the Certified Managed Care Nurse (CMCN). To be eligible for this certification, nurses must have a valid RN license.
How Much Does a Managed Care Nurse Make Per Year?
Managed care nurses make approximately the same as social and community service managers, which is an average of $74,240 per year, according to the U.S. Bureau of Labor Statistics (BLS). Salaries can change with location and experience, with a low-end average of $46,770 and a high-end of $123,320. Depending on the workplace type, employers may be able to offer higher or lower compensation:
Insurance Carriers: $124,760
Agencies, Brokerages, and Other Insurance Related Activities: $117,790
Scientific Research and Development Services: $115,330
Federal Executive Branch (OEWS Designation): $114,060
General Medical and Surgical Hospitals: $106,910
Local Government: $96,050
Nursing and Residential Care Facilities: $64,030
Community and Vocational Rehabilitation Services: $63,370
The West Coast, New England states, and Alaska may offer the best managed care nursing pay, but the cost of living in these areas can also be high. The lowest paying states are in the Midwest and some southeastern states.
According to healthcare spending projections compiled by the Centers for Medicare & Medicaid Services, through the year 2031, average national health expenditures growth is expected to outpace the growth of the U.S. economy. With numbers like these, managed care programs will be looking for nurses to help them budget appropriately and balance quality care with cost-saving techniques.
On top of that, nurses across all specialties are in short supply. According to the U.S. Department of Health and Human Services, 24% of U.S. hospitals have reported critical staffing shortages, and at least eight states have had to call in help from the military for staffing. Nurses in all fields will stay in high demand for some time to come.
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