A nurse's role when working in a hospital, home health and/or out-
patient practice is primarily as a clinician with additional duties to
document insurance information and health care utilization. Primarily
her/his role is to provide patient care. Along with clinical care,
registered nurses will provide intake and discharge of patients to and
from the facility and coordinate with specialists and social services.
The claims examiner or health insurance specialist (often with a
clinical title) verify claims against third-party payer requirements in
order to authorize payment. They may refer the claim to an
investigator for more scrutiny to make sure that the billed costs are
accurate. Often these roles are filled by RNs because the examiner
must determine if the treatments and procedures a patient receives
are necessitated by the diagnosis. Therefore, the examiner must have
specific knowledge of medical procedures.
b A health information manager working in a medical office may
manage the practice as well as be responsible for medical billing,
coding, record keeping, and other medical office administrative
duties. However, a health information manager specializing in health
data analysis might work for a non-profit research center,
government agency, hospital, or private healthcare management
company that is interested in improving outcomes and controlling
costs. The management of information in this case may differ from
the private medical office practice in the scope of data analysis, such
as focusing on factors like re-admittance rates to a hospital or length
of patient stay after a surgery or procedure. Health care data analysis
for government or a research group may want to look at long-term
outcomes and health care expenditures. National health information
data collections compiled by government or research groups are
comprised of health and demographic data and allow states,
healthcare management companies, and private industry to plan and
assess healthcare outcomes and make clinical decisions about best
practices (McGrath, et al, 2022). Staff at healthcare facilities
routinely collect information about the services, patients’ health and
the type of treatments and tests they receive in order to improve
patient care (Leon, et al, n.d.). Data analysis conducted for hospitals is
often informed more by patients’ needs as opposed to insurance
companies and health management organizations that are interested
primarily in profits and growth.
References
Bowie, M. (2019). Essentials of Health Information Management:
Principles and Practices. 4th Edition. Cengage, Boston, MA.
Leon, N., Leon, N., Balakrishna, Y., Hohlfeld, A., Odendaal, W. A.,
Schmidt, B.-M., Zweigenthal, V., Anstey Watkins, J., & Daniels, K.
(n.d.). Routine Health Information System (RHIS) improvements for
strengthened health system management. Cochrane Database of
Systematic Reviews, 8.
McGrath, N., Foley, B., Hurley, C., Ryan, M., & Flynn, R. (2022). A
multi-method quality improvement approach to systematically
improve and promote the quality of national health and social care
information. Health Information Management Journal, 51 (1), 50–56.
https://doi-org.ezproxy.snhu.edu/10.1177/1833358320926422
