In a managed care organization, the triage nurse listens to the patient describe the problems and symptoms, reviews the patient's medical record, decides which course of intervention is most appropriate, and advises the patient accordingly. This mechanism for directed access to health care services achieves more efficient and effective utilization of the health care delivery system. A function that is tied closely to quality improvement and utilization management is risk management, which involves decreasing the probability of incurring adverse outcomes. Because nurses have direct access to and responsibility for patient care, they are in excellent positions to identify potential risk factors and to determine what situations may be detrimental to patients. The analysis shows not only individual events, but patterns and frequencies of events and possible system design defects contributing to the occurrence.
Evaluation is conducted to formulate alternative approaches to reducing the identified risks.
Treatment involves implementation of corrective intervention strategies to reduce the risk factors. The role of the provider liaison is to furnish information and to interact with other health care professionals regarding patient-related and administrative issues. The provider liaison can ensure that all health professionals understand each other's functions and responsibilities. It is an important role when many health care providers are caring for the same individual, since the organizational structure of managed care calls for collaboration, cooperation, and coordination among all health care professionals. Benefits Interpreter Managed care organizations need a mechanism to explain their authorization and control functions to their members and to handle any complaints and grievances that may arise.