A Day in the Life: A Medicare Care Manager

A Day in the Life: A Medicare Care Manager

Apr 15 2016

One of the questions Rick Stiles hears a lot is, “What exactly does an insurance nurse do?”

Rick Stiles is a Registered Nurse and health care professional on the Priority Health Medicare Care Management team. Rick and his colleagues start their day by reviewing the members they are scheduled to speak to and prioritizing those with the most need.

Just Another Day

A typical day for a Medicare Care Manager may consist of talking with members after they come home from the hospital about their recovery plan and their long term health needs.They also may follow up with members based on a doctor’s recommendation. Or proactively contact a member whose claims data indicates his health situation is changing to see if they can offer assistance or guidance. No matter the situation, the role is clear; help members reach their health goals.

Dave’s Story

Before coming to Priority Health almost five years ago, Rick spent 15 years as a visiting nurse for Spectrum Health. Being a home nurse has helped him immensely in his current role.

“Many home care people are on Medicare,” he said. “So when our members are describing their home and social situation, I can picture what they are telling me.” He has also learned to read between the lines and ask the right questions.

Those skills were put to the test with Dave*, a member dealing with several chronic diseases. One of those diseases was Type 2 Diabetes, and Dave wasn’t managing his blood sugar levels well. While building a trusting relationship with Dave, Rick discovered that his vision was poor and that he had trouble reading his glucometer results. To give Dave back some control, Rick worked to get Dave a new glucometer that “speaks” the results instead.

“We really care about their health,” Rick is quick to include. “As a nurse, I get my fulfillment out of helping people. And I do that here.”

Another reason Dave wasn’t managing his health was because he didn’t want to burden his daughter, with whom he was living, with his needs.Throughout their conversations, Rick sensed that Dave was dealing with some depression and was able to get him help for that, too.

“If we just focused on physical issues, then the barriers from other areas of their life would keep them from following through with what they need to do to be physically well,” Rick said.

Community Network Support

Rick and the care management team don’t just work within each member’s Priority Health Medicare plan. They know the community resources available and draw on a network of services to help members. They know of resources for people with financial issues or who need assistance with their care. They help connect the dots for members and their health care goals.

“Advocate is one of the best words to describe what we do,” said Rick.

Leadership is Key

From Rick’s experience, he thinks that the leadership affects the atmosphere and the mindset of the department. “If I thought the leadership here was only interested in the dollars, I would find another place to work,” he said.

There are 64 care management initiatives at Priority Health, all designed to partner with its members to help them be at their healthiest.

“We really care about their health,” Rick is quick to include. “As a nurse, I get my fulfillment out of helping people. And I do that here.”

As for Dave, time will tell whether he will meet his health goals. But one thing is for sure, Rick will be there for him to offer support and motivation every step of  the way.

*Names have been changed for this story.

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