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Day in the Life of a Clinical Nurse Adviser for a Medical Insurance Company

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Name: Tristana Rodriguez
Role: Clinical Nurse Adviser, Medical Insurance Company
Location: Brighton
Wage/Band: Band 6
Previous job: Nurse Case Manager, also Medical Insurance

The role that I do

Overall my job involves being on hand for the business as a whole to answer any medical-related queries. It ranges from quick questions and answers to sitting in meetings about very complex, technical cases, explaining the implications of the medical details to non-clinical colleagues. As well as my medical knowledge I need to be able to interpret the insurance policies and understand our legal responsibilities.

Our aim is to treat each member of our schemes fairly and because every case will have slightly differing circumstances, we have to consider each person objectively in accordance with their policy guidelines. Insurance companies can have something of a negative image, but in fact the industry is heavily regulated to ensure fairness.

With clinicians on hand internally, when a case is unusual or intricate we can ensure that decisions as to whether the case meets the eligibility criteria are made based on sound clinical judgement.

I work as a team of four Clinical Nurse Advisers and in addition to this general remit we each also have separate specialist areas. My particular responsibility is to the Pre-Authorisation team, who deal with calls, emails and faxes from members and healthcare providers who need to confirm cover for treatment. Other than this I can be called on for a huge variety of reasons and get invited to take part in projects throughout the business.

The skills it requires

I would say that good interpersonal skills are vital in this role as we have to work with colleagues from all over the business with hugely diverse backgrounds, experience and knowledge. You also need an objective, analytical eye to view each case fairly on its own merits.

Other key attributes needed for the post

I think that although nurses often deal with highly technical equipment clinically, we are culturally very unconfident in terms of computer literacy, and until recently, I would have included myself in that. Of course my IT skills have improved greatly since I started working in an office environment, but I think that even in the clinical setting many nurses would be amazed how much IT can help access and organise information if they only had the confidence and support to confront their fear.

Key relationships/working with other members of staff

As claims progress they may pass from one clinician’s responsibility to another, so good communication with my team is paramount to consistency, in the same way it would be to achieve continuity of care in the clinical setting.

My association with the pre-auth team also means that I aim to act as an integral part of the team, sitting in on team meetings and getting involved in any social/ charity events that happen. It is key to my role that members of the team find me approachable and supportive so that I am made aware of any issues affecting decision-making.

Key ups and downs of the post

For me there isn’t really a huge downside to the post. I love the human element of the role, meeting people and discussing complex issues, balanced with the intellectual challenge of understanding human medicine, which I find fascinating.

Occasionally I miss the “feel good factor” of hands-on nursing, but a job which is less demanding emotionally has freed up some energy for me to invest in close family and friends.

Occasionally the answer we have for members is an out-and-out “no” to cover for a particular treatment, which generally goes against nurses’ natural tendency to help people and go the extra mile. However, I take pride in adopting a professional approach to this, promoting a culture of openness and honesty so that our members can have confidence that when we look into their cases, a methodical and fair process is taking place, rather than the company simply aiming to avoid providing cover, as is often the perception.

Career progression possibilities

As nurses are something of a new phenomenon in my particular part of the business, potentially we have huge scope to carve out our own career paths, within reason. Elsewhere in the company, a nurse has reached the role of assistant medical director, so I guess the sky’s the limit!

Personal job satisfaction levels

I see myself as quite a practical person and need to feel “useful” but at the same time I found clinical nursing so busy that there wasn’t time (or energy!) to really research systems of the body and the mechanisms which lead to disease. This job enables me to work side-by-side with others but also allows me to get my teeth into some really complex areas of pathophysiology. I love the detective, analytical aspect of the work and would recommend it to anyone who has a passion for medicine or who would like to try working in an office environment.

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