What Does a Utilization Review Nurse Do?

Utilization review nurses are responsible for ensuring that health care services are being delivered in a cost-effective manner. They commonly work with insurance companies to ensure that claims are valid and that patients are receiving the best possible treatment.

Utilization review nurses may also be involved in quality assurance initiatives, helping hospitals or other medical facilities identify ways to improve patient outcomes or reduce costs.

Utilization Review Nurse Job Duties

Utilization review nurses have a wide range of responsibilities, which can include:

• Coordinating with physicians to make sure they are aware of all treatment options and their risks and benefits
• Tracking all medical records to ensure they are accurate and up to date
• Performing initial assessments of patients to determine their needs and develop treatment plans
• Providing education on health and wellness topics to patients and their families in order to foster positive lifestyle changes
• Communicating with insurance companies about coverage choices and claims denials for services rendered or medications prescribed
• Recommending changes to treatment plans based on new information about a patient’s condition
• Conducting post-discharge follow-up calls to ensure that patients are adhering to their treatment plans
• Scheduling patients for appointments with specialists, therapists, or other providers
• Reviewing patients’ medical records to identify errors or missed diagnoses that could have been detected earlier in treatment

Utilization Review Nurse Salary & Outlook

Utilization review nurses’ salaries vary depending on their level of education and experience, the company size and geographic location.

• Median Annual Salary: $76,500 ($36.78/hour)
• Top 10% Annual Salary: $106,000 ($50.96/hour)

The employment of utilization review nurses is expected to grow faster than average over the next decade.

As healthcare costs continue to increase, health insurance companies and health care providers will continue to seek ways to reduce costs. Utilization review nurses will be needed to evaluate whether treatments and tests are appropriate for patients.

Related: 25 Utilization Review Nurse Interview Questions and Answers

Utilization Review Nurse Job Requirements

A utilization review nurse typically needs to have the following qualifications:

Education: Utilization review nurses are required to have a minimum of a bachelor’s degree in nursing. They can earn a bachelor’s degree in nursing in four years and can expect to take courses in anatomy, physiology, microbiology, pharmacology and health assessment.

Training & Experience: Utilization review nurses receive on-the-job training to learn the specific processes and procedures of the facility. This training may include shadowing a current utilization review nurse or learning from a supervisor. Training may last for a few weeks or months, depending on the size of the facility and the complexity of the processes.

Certifications & Licenses: To become a utilization review nurse, you will need to earn a registered nurse license. Every state has a different process for doing so, but they all require you to pass a nursing exam. You may need to pass other tests depending on the position you are applying for.

Utilization Review Nurse Skills

Utilization review nurses need the following skills in order to be successful:

Communication: Communication is the ability to convey information to others in a clear and understandable way. Utilization review nurses must be able to communicate with patients and other medical professionals to ensure the patient’s needs are met. They must also be able to communicate with insurance companies to ensure the patient is receiving the correct treatment.

Critical thinking: Critical thinking is the ability to analyze a situation and make a decision based on the information you have. Utilization review nurses must be able to make decisions about whether a patient is ready to be discharged from the hospital. This requires the ability to analyze the patient’s condition and make a judgment call about whether they are ready to be released.

Time management: Time management is the ability to prioritize tasks and manage deadlines. Utilization review nurses often have many tasks to complete in a short period of time. This requires them to prioritize tasks and manage their time effectively. For example, a utilization review nurse may need to review a large number of medical records and conduct a review of a patient’s medical history. They may prioritize the review of the medical records over the review of the patient’s medical history if the review of the medical records is due sooner.

Medical knowledge: Medical knowledge is the ability to understand medical terminology and procedures. Utilization review nurses need to have a strong understanding of medical conditions and treatments to be able to assess the appropriateness of a patient’s care. Medical knowledge can also help you to identify any potential risks to a patient’s health and safety.

Teamwork: Utilization review nurses work with other medical professionals to ensure their patients receive the best care possible. This often involves working with other nurses, physicians, case managers and other medical professionals. Being able to work well with others is an important skill for utilization review nurses to have.

Utilization Review Nurse Work Environment

Utilization review nurses work in a variety of settings, including hospitals, insurance companies, and government agencies. They typically work full time, and some may work overtime or be on call. Utilization review nurses often work with a team of other nurses and medical staff to review patient records and make recommendations about treatment. They may also work with patients to explain their treatment options and help them make decisions about their care. Utilization review nurses must be able to handle a high volume of work and be able to make quick decisions. They must also be able to work well under pressure and be able to handle a high level of stress.

Utilization Review Nurse Trends

Here are three trends influencing how utilization review nurses work. Utilization review nurses will need to stay up-to-date on these developments to keep their skills relevant and maintain a competitive advantage in the workplace.

The Need for More Patient-Centered Care

The healthcare industry is rapidly changing, and one of the most significant changes is the move towards patient-centered care. This shift means that nurses will need to be able to provide more personalized care by understanding the needs of each individual patient.

Utilization review nurses are well-positioned to take advantage of this trend, as they are responsible for reviewing the medical records of patients who have been hospitalized for longer than 48 hours. By doing so, they can help ensure that patients are receiving the care that they need and are not being over- or under-treated.

More Use of Technology in Healthcare

As technology continues to evolve, it is becoming increasingly common for hospitals to utilize it in their day-to-day operations. This includes using technology to improve communication between doctors and nurses, as well as using electronic health records (EHRs) to track patient data.

As a utilization review nurse, you can capitalize on this trend by becoming familiar with the latest technologies and how to use them effectively. This will allow you to work more efficiently and provide better care for your patients.

Patient Advocacy Becomes More Important

As patient advocacy becomes more important in the healthcare industry, nurses who specialize in this area will become more valuable.

Patient advocacy involves helping patients understand their rights and providing support during difficult times. Nurses who are skilled in this area can make a huge difference in the lives of patients and their families, which makes them extremely valuable employees.

How to Become a Utilization Review Nurse

A career as a Utilization Review Nurse can be very rewarding. It offers the opportunity to make a difference in people’s lives and help them get the care they need. However, it is important to consider all aspects of this career before jumping in.

One of the most important things to think about is where you want to work. There are many different settings in which you can practice UR nursing. You can work for a health system, hospital, insurance company, or medical group. Each setting has its own unique culture and environment, so it is important to find one that fits your personality and style.

You should also consider what type of patients you want to work with. Some nurses prefer to work with only certain types of patients, such as those who have long-term conditions or who are elderly.

Another important factor to consider is how much travel you are willing to do. Many nurses spend time traveling between different facilities to see their patients. This can be difficult if you have a family or other obligations.

Advancement Prospects

Utilization review nurses may advance to positions with more responsibility, such as case management or utilization review coordinator. They may also move into management positions, such as director of utilization review or director of case management. Some utilization review nurses may become independent consultants.

Utilization Review Nurse Job Description Example

As a utilization review nurse at [CompanyX], you will play a vital role in ensuring that our patients receive the care they need while also staying within the bounds of their insurance coverage. You will be responsible for reviewing patient records to determine the appropriateness of admissions, length of stay, and level of care. You will also collaborate with the interdisciplinary team to develop a plan of care that is medically necessary and cost-effective. In addition, you will monitor the progress of patients to ensure that they are receiving the care they need and that their insurance coverage is being utilized appropriately.

The ideal candidate for this position will be a Registered Nurse with experience in utilization review, case management, or discharge planning. He or she will be highly organized, detail-oriented, and able to work independently. Additionally, the ideal candidate will have strong communication and interpersonal skills.

Duties & Responsibilities

• Review medical records to determine the appropriateness of inpatient admissions, level of care, and length of stay
• Utilize clinical knowledge and skills to perform concurrent reviews for inpatient services
• Collaborate with physicians and other health care professionals to ensure that the plan of care is medically necessary and meets the patient’s needs
• Perform retrospective reviews of inpatient stays to ensure that the level of care was appropriate and that discharge planning was done in a timely manner
• Identify opportunities for improvement in the utilization of resources and make recommendations to the case management team
• Serve as a resource to the case management team on issues related to utilization review and managed care
• Keep abreast of developments in the field of utilization review and managed care through reading professional literature and attending educational seminars
• Participate in quality assurance activities to ensure that the utilization review process is being followed correctly
• Maintain accurate and up-to-date documentation in the patient’s medical record
• Prepare reports on utilization patterns and trends for the case management department
• Participate in interdisciplinary rounds to provide input on the appropriateness of the plan of care
• Assist in the development and implementation of utilization review policies and procedures

Required Skills and Qualifications

• Registered Nurse (RN) with current, unrestricted license to practice in state of residence
• Bachelor’s degree in nursing or related field
• 3-5 years clinical experience in an acute care hospital setting
• Utilization review or case management experience preferred
• Strong understanding of Medicare, Medicaid, and other third-party payer regulations
• Ability to work independently with little supervision

Preferred Skills and Qualifications

• Master’s degree in nursing or related field
• 5+ years clinical experience in an acute care hospital setting
• Utilization review or case management experience required
• Experience working with an interdisciplinary team
• Demonstrated ability to think critically and make sound decisions