Utilization Review Nursing with Michelle Wyatt (Part 1)

This is the first in a two-part interview with P. Michelle Wyatt, DNP, MSN, RN, IQCI, CPHM, who has spent nearly two decades in utilization management and currently serves as Clinical Best Practice Director at XSOLIS, a position which allows her to support and hear from case management teams and leaders across the nation. The second part of Michelle’s interview can be found here.

Michelle, what is your background and how did you wind up in utilization management?

I started my nursing career as a Licensed Practical Nurse, spending about four years in a pediatrics physician practice that consisted of nine offices in the Middle Tennessee area. I served as a charge nurse for a time then transitioned to a training and education role that also involved hiring and recruiting for the practice.

I wanted to grow in my career, so when Tennessee’s Medicaid expanded and rebranded to TennCare, I worked as a care management specialist at two different organizations on the payer side – which was my first introduction to utilization management. I then transferred that skillset to the Medicare side as a fraud investigator, spending about three and a half years investigating suppliers for fraudulent claims submitted to Medicare. This experience gave me a real appreciation for work well done and gave me a different appreciation for what healthcare can do differently to improve as an industry.

I then was approached with an opportunity in Nashville to do utilization management at a hospital system, which I jumped at. I’m always someone who wants to learn and grow in leadership, case management and utilization review, and this job allowed me to do just that. I served as a nurse, then team lead, then manager, then director – and during this time I got my Associates in Nursing and followed that with my Bachelor’s and Master’s in Nursing.

What motivated you to take that growth approach to education and leadership?

Learning is something I continue to do because it has been ingrained in me. My grandmother was also a huge influence – after I received my bachelor’s, she suffered a massive stroke and our family took care of her. A few months before she passed, she encouraged me to continue my education and I started work on my master’s right after she passed.

Utilization review has been a love of mine for quite some time – after all, I’ve been doing it for nineteen years. I’ve had some good professors who saw something within me that I didn’t see within myself and two physician advisors on staff during this time were constant encouragers and motivators for me. They were the ones who encouraged me to pursue my doctorate, which I did. Having seen utilization management from both the hospital and insurer side, I saw such opportunity to make a difference in patient’s lives as well as the lives of those I worked with.

Looking back on your experience and your journey, what advice would you give to case management leaders?

There are two big pieces of advice I share with others: connect with others and educate yourself. As a leader, I truly believe you can’t talk to your people enough – you have to know how to blend, to manage, to understand. And you must have that personal touch. As they say, there is no I in team. As nurses, we are patient advocates. As leaders, we are staff advocates. We serve as their voice, their encouragers, their supporters.

And as a part of that, you must educate yourself. Walking a mile in their shoes means you know each facet of the job by heart. As a case management leader and as a partner to teams across the nation now, I can say that I’ve been in your shoes. I’ve seen the good, the bad, the ugly of case management. I’ve been on hold for 45 minutes with a payer, I’ve done countless patient reviews, I’ve enjoyed learning and growing within the industry. Our job as leaders is to bridge the gaps and put our people first.