Career Paths: Clinical, UM experience gives AM a career edge
Upfront collections are another focus
A varied mix of clinical, utilization review (UR), and referral management training and experience helped prepare Linda Dullin, RN, for her current role as admitting director at Straub Clinic and Hospital in Honolulu.
Her nursing education and background have aided communication between the admitting area and Straub’s clinical staff, Dullin says, and stints in an "Ask-A-Nurse" program and as a managed care coordinator have made her a knowledgeable participant in the organization’s utilization management (UM) and discharge planning decisions.
"When patients come into the admitting area and a bed is not ready," she notes, "I’m able to recognize what we need to do — if the patient is not clinically stable, when to push or to make alternate plans." Those plans, Dullin adds, might include taking the patient to a bed in the emergency department (ED).
Dullin’s experience working for HMSA, which is Hawaii’s network of Blue Cross Blue Shield, she notes, made her familiar with the ins and outs of patient benefits, and years spent in the Ask-A-Nurse program provided valuable information about services available in the community.
"[The UM staff] have a weekly meeting," Dullin points out, "where they review increased length of stay and high-risk cases. These may be patients who are homeless, or who may not have financial resources." Technically, she says, the group is made up of case managers and the medical director of UM, "but myself and one of the financial counselors are ex officio members."
Dullin began working as a nurse’s aide in 1968, later became a licensed practical nurse, and got her credentials as a registered nurse in 1980. "I worked in an acute-care hospital the majority of the time, and was totally on the clinical side until 1986," she adds.
Here’s a snapshot look at three positions that have brought Dullin to where she is today:
- Ask-A-Nurse.
Between 1986 and 1990, Dullin worked for an "Ask-A-Nurse" program jointly sponsored by two Oahu hospitals, Queens Medical Center and Castle Medical Center. In that job, Dullin explains, she used specific criteria to determine if cases were emergent, urgent, or could be handled with a physician office visit.
Dullin also connected callers with classes offered by the hospitals, and made physician referrals, matching them according to insurance requirements and location, she adds.
- Admission nurse coordinator.
In 1990, Dullin made her first foray into the access area. As admission nurse coordinator at the Queens Medical Center, she supervised the preadmission area and the registration area for the hospital’s radiology department, she says. "I oversaw a staff of 14, who were responsible for preadmits and preregistration for inpatient and outpatient admissions and surgeries, radiology procedures, and any type of prescheduled outpatient diagnostic test or service."
"My nursing ability enabled me to determine the right place of treatment for the patient," Dullin notes. "The physician may have ordered an inpatient stay, but I recognized that the person should be an outpatient." That experience, she adds, put her in good stead for the challenges of patient placement in today’s health care environment.
After six years in that job — and 26 years with that hospital — Dullin became a casualty of "right-sizing" when the position of nurse coordinator was eliminated, she says. "That was kind of a traumatic experience," adds Dullin, who says she took a trip to the Pacific Northwest and then came home to work on her next career move.
"One of the severance package components was that I was able to work with a human resources company," she says, "to brush up the resume, set up interviews and go over interview questions. I’d been out of the job market for 26 years."
- Managed care coordinator.
In November 1996, Dullin assumed the position with HMSA, doing referral management and practice management. "The company had health center or HMO clients and physician groups that needed to have someone oversee the utilization of referring outside of their health center," she explains.
As managed care coordinator, Dullin helped get referrals for the membership to go to an outside specialist or facility, she says. "My clinical background was very helpful as far as recognizing the type of admission, and also in recognizing whether there were specialists available within [the organization], which was a cost-saving."
"It was something brand new; a new concept to the subsidiary, so I helped build the program from the ground up."
Extra jobs enhanced experience
Throughout her career, Dullin says, she often has held more than one job at a time. While working as a nurse, for example, she also had a job with Sheraton Hotels, handling first-aid and CPR training and keeping track of employee and guest injuries and accidents at a facility with 1,300 employees. While holding down the Ask-A-Nurse position, she adds, Dullin also did medical/legal reviews for an attorney.
That attorney might, for example, be representing an insurance company, and ask her to review the medical record associated with a particular case, Dullin says. "I’d get those [records] to digest and be able to extrapolate whether there was a prior history of an accident or complaints. Or, I might say to the attorney, You need to check this out before settling with the insurance company.’"
Before taking her current job as admitting director, Dullin notes, she was sought out by Straub’s chief financial officer, who had heard about her from a woman Dullin had supervised at Queens Medical Center.
"At that time, admitting had just gone under business services and they were making significant managerial changes," she says. It’s likely that her background in nursing, as well as her referral management and UR experience, helped her get the director position, Dullin suggests.
Another plus was that she had been heavily involved in instituting a price-quoting system and improving upfront collections during her 1990-1996 tenure at Queens, she adds. "Queens is a not-for-profit hospital, and recognized there was an opportunity [to improve the bottom line], and that this also was a component of good customer service." As part of that effort, Dullin adds, she worked with her staff on the practice of making payment arrangements with customers.
Straub is in the process of refining its upfront collections program, she notes. "Because it’s a clinic and a hospital and we have physicians located here, the physicians’ offices are notifying patients at the point of service of their copayments and self-pay balances, and collecting."
Several financial counselors in the admitting area had reported to Dullin, but in August 2001 went under the oversight of one of the business services managers, she says.
Those financial counselors, however, continue to work as a team with access personnel, Dullin points out, in regard to verifying the status of self-pay patients in the ED. "They also handle the inpatients that we admit overnight.
As part of a five-year work plan set in place under Straub’s recent merger with three other hospitals, Dullin says the admitting area will be a focus in all four hospitals.
"We will be continuing a customer service initiative that started in business services," adds Dullin, who expects her past experience to serve her well in this endeavor. This initiative will involve internal and external customers, she says, and will look, among other things, at strengthening the working relationship and communication between the ED front desk and the ED medical staff.
"Because of EMTALA [Emergency Medical Treatment and Active Labor Act] laws, we can only do so much [in registering the patient]," she says. "We have a high percent of our admissions through the ED, and before we proceed, it’s imperative to have good communication [with clinical staff]."
Stabilizing staffing is among her top goals for the coming year, Dullin adds. Part of the challenge there, she notes, is that there is no specific school or training for access representatives. "It’s hard to teach good customer service," Dullin says, "so I look for that first, and after that try to find some experience that is related [to access]."
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