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How to Become a Utilization Review Nurse

What Does a Utilization Review Nurse Do?

UR nurse and medical team

Utilization review (UR) nurses work behind the scenes to maximize the quality and cost efficiency of health care services. Through regular reviews and audits, they ensure that patients receive necessary care without burdening the health care system with unnecessary procedures, ineffective treatments or overlong hospital stays. UR nurses also help insured persons to make informed decisions about their health care by educating them on the benefits and limitations of their Medicare, Medicaid or private health care coverage.

In healthcare organizations and insurance companies, there is considerable overlap between case management and utilization review/management roles; these jobs may still be separate hires, but the knowledge base is virtually identical. After 1-2 years of employment in this area of nursing, you should consider becoming a certified case manager, or CCM, a certification offered by the Commission for Case Manager Certification.

Utilization review is a relatively new idea that has evolved since the 1980s alongside the concept of managed care. Experienced nurses are uniquely suited to this work due to their extensive knowledge of patient care, medical treatments and hospital procedures. They rely on their clinical judgment, honed over years in acute care settings, to make responsible decisions that promote patient health and wellbeing while keeping resources available to those most in need.

UR nurses advise insurance companies and health care facilities on questions of hospital admission, length of stay, imaging studies, surgeries, medications, referrals and many other treatments and procedures. To formulate these recommendations, they review medical records, talk to patients and providers and conduct additional research as needed. Those UR nurses employed by the insurance industry follow strict protocols to determine whether patients meet the standards for insurance reimbursement. They also pre-certify people for medically necessary procedures and hospitalizations and, at times, travel to visit with patients and providers.

Other UR nurses work in hospitals, nursing homes and clinical settings where they manage patient care through daily case reviews and create discharge plans that help patients transition smoothly and safely to their homes or other facilities. These professionals have a significant amount of patient and family contact, as they must often explain the rationale behind their recommendations. They also work closely with insurance companies to ensure that the provider will be reimbursed for services rendered.

You can begin working in utilization review with a variety of degree qualifications and professional licenses. Hospital utilization review nurses are registered nurses (RNs), usually BSN-RNs with diverse floor experience and several years of work in direct patient care. In primary care and nursing home settings, a licensed practical nurse (LPN) may conduct utilization review, though this role is more typically filled by an RN.

While the work sometimes involves difficult decisions, UR nursing ensures that health care facilities can provide appropriate care for the greatest number of people. Careful resource management allows hospitals to serve entire communities, including those who are uninsured or underinsured. These professionals also play an important role in containing health care costs, which preserves access to care for middle class families.

Workplace Details

Insurance companies, health care providers, workers compensation bureaus, the military, correctional facilities and government agencies such as Medicare and Medicaid all employ UR nurses. These professionals spend much of their time at their desks and computers reviewing medical records and writing recommendations. Some positions require frequent travel. UR nurses typically work regular business hours. A growing number work remotely from home offices.

Salary and Job Outlook

State
Average Wage
California
$101750
Texas
$70390
New York
$80830
Florida
$64630
Pennsylvania
$68770

Hover over any state to explore local income and job growth data.

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ALABAMA

Median Salary: 
$55,500
Bottom 10% (Entry Level): $41,600
Top 10% (Lots of Experience): $76,000

2014-2024 Job Growth: 17%
Projected Annual Job Openings: 1,870

SALARY BY METRO AREA:

CityEntry LevelMedianLots of Experience
Birmingham$43,240$57,670$77,370
Huntsville$41,840$56,800$75,450

ALASKA

Median Salary: 
$88,100
Bottom 10% (Entry Level): $65,200
Top 10% (Lots of Experience): $116,900

2014-2024 Job Growth: 10%
Projected Annual Job Openings: 190

SALARY BY METRO AREA:

CityEntry LevelMedianLots of Experience
Anchorage$65,100$88,940$117,550
Fairbanks$69,190$98,120$119,580

ARIZONA

Median Salary: 
$71,500
Bottom 10% (Entry Level): $52,400
Top 10% (Lots of Experience): $96,100

2014-2024 Job Growth: 22%
Projected Annual Job Openings: 3,500

SALARY BY METRO AREA:

CityEntry LevelMedianLots of Experience
Phoenix$52,850$73,400$97,630
Tuscon$52,510$67,590$82,510

ARKANSAS

Median Salary: 
$55,700
Bottom 10% (Entry Level): $40,100
Top 10% (Lots of Experience): $76,700

2014-2024 Job Growth: 15%
Projected Annual Job Openings: 870

SALARY BY METRO AREA:

CityEntry LevelMedianLots of Experience
Little Rock$42,070$60,690$84,170
Fort Smith$39,910$52,140$63,430

CALIFORNIA

Median Salary: 
$100,400
Bottom 10% (Entry Level): $64,400
Top 10% (Lots of Experience): $147,100

2014-2024 Job Growth: 17%
Projected Annual Job Openings: 10,470

SALARY BY METRO AREA:

CityEntry LevelMedianLots of Experience
Los Angeles$63,400$95,940$129,340
San Francisco Bay$83,120$132,970$167,920
San Diego$57,610$85,470$126,550
Sacramento$67,060$116,690$155,890

COLORADO

Median Salary: 
$68,500
Bottom 10% (Entry Level): $51,200
Top 10% (Lots of Experience): $95,100

2014-2024 Job Growth: 33%
Projected Annual Job Openings: 2,350

SALARY BY METRO AREA:

CityEntry LevelMedianLots of Experience
Denver$51,510$70,580$97,080
Colorado Springs$51,430$63,590$88,590

CONNECTICUT

Median Salary: 
$76,500
Bottom 10% (Entry Level): $55,300
Top 10% (Lots of Experience): $100,700

2014-2024 Job Growth: 6%
Projected Annual Job Openings: 990

SALARY BY METRO AREA:

CityEntry LevelMedianLots of Experience
Hartford$55,130$76,020$97,630
Bridgeport$56,590$75,830$103,110
New Haven$57,470$78,720$105,440

DELAWARE

Median Salary: 
$71,100
Bottom 10% (Entry Level): $53,800
Top 10% (Lots of Experience): $93,300

2014-2024 Job Growth: 17%
Projected Annual Job Openings: 420

SALARY BY METRO AREA:

CityEntry LevelMedianLots of Experience
Wilmington$54,470$72,460$93,860
Dover$52,740$64,500$84,490

DISTRICT OF COLUMBIA

Median Salary: 
$79,600
Bottom 10% (Entry Level): $55,300
Top 10% (Lots of Experience): $103,800

2014-2024 Job Growth: 11%
Projected Annual Job Openings: 380

SALARY BY METRO AREA:

CityEntry LevelMedianLots of Experience
Washington DC$53,890$76,030$101,360

FLORIDA

Median Salary: 
$62,100
Bottom 10% (Entry Level): $46,100
Top 10% (Lots of Experience): $82,900

2014-2024 Job Growth: 25%
Projected Annual Job Openings: 8,110

SALARY BY METRO AREA:

CityEntry LevelMedianLots of Experience
Miami$50,250$65,560$91,660
Orlando$43,490$61,570$79,250
Tampa$49,770$62,990$84,660
Jacksonville$48,910$61,610$79,810

GEORGIA

Median Salary: 
$63,100
Bottom 10% (Entry Level): $44,200
Top 10% (Lots of Experience): $80,900

2014-2024 Job Growth: 20%
Projected Annual Job Openings: 2,980

SALARY BY METRO AREA:

CityEntry LevelMedianLots of Experience
Atlanta$47,500$67,010$82,160
Augusta$46,880$65,910$88,340

HAWAII

Median Salary: 
$92,300
Bottom 10% (Entry Level): $63,400
Top 10% (Lots of Experience): $119,400

2014-2024 Job Growth: 13%
Projected Annual Job Openings: 400

SALARY BY METRO AREA:

CityEntry LevelMedianLots of Experience
Honolulu$63,930$93,970$120,600

IDAHO

Median Salary: 
$61,000
Bottom 10% (Entry Level): $44,600
Top 10% (Lots of Experience): $78,400

Job Growth Data Not Available

SALARY BY METRO AREA:

CityEntry LevelMedianLots of Experience
Boise$46,390$61,760$78,900

ILLINOIS

Median Salary: 
$67,100
Bottom 10% (Entry Level): $45,600
Top 10% (Lots of Experience): $99,600

2014-2024 Job Growth: 11%
Projected Annual Job Openings: 3,970

SALARY BY METRO AREA:

CityEntry LevelMedianLots of Experience
Chicago$51,580$73,220$103,790
Rockford$43,920$59,400$87,180

INDIANA

Median Salary: 
$57,900
Bottom 10% (Entry Level): $41,900
Top 10% (Lots of Experience): $78,600

2014-2024 Job Growth: 19%
Projected Annual Job Openings: 2,510

SALARY BY METRO AREA:

CityEntry LevelMedianLots of Experience
Indianapolis$43,290$61,450$81,840
South Bend$43,460$58,310$76,100
Fort Wayne$40,640$53,490$73,350

IOWA

Median Salary: 
$53,900
Bottom 10% (Entry Level): $40,700
Top 10% (Lots of Experience): $73,800

2014-2024 Job Growth: 16%
Projected Annual Job Openings: 1,280

SALARY BY METRO AREA:

CityEntry LevelMedianLots of Experience
Des Moines$41,010$56,420$75,160
Cedar Rapids$39,730$50,730$74,600

KANSAS

Median Salary: 
$56,300
Bottom 10% (Entry Level): $41,700
Top 10% (Lots of Experience): $76,600

2014-2024 Job Growth: 8%
Projected Annual Job Openings: 760

SALARY BY METRO AREA:

CityEntry LevelMedianLots of Experience
Wichita$41,060$51,440$72,980
Kansas City$44,940$63,260$81,370

KENTUCKY

Median Salary: 
$58,000
Bottom 10% (Entry Level): $42,600
Top 10% (Lots of Experience): $77,000

2014-2024 Job Growth: 36%
Projected Annual Job Openings: 2,670

SALARY BY METRO AREA:

CityEntry LevelMedianLots of Experience
Louisville$44,330$61,510$78,730
Lexington$44,220$59,870$76,890

LOUISIANA

Median Salary: 
$59,800
Bottom 10% (Entry Level): $42,900
Top 10% (Lots of Experience): $83,300

2014-2024 Job Growth: 16%
Projected Annual Job Openings: 1,910

SALARY BY METRO AREA:

CityEntry LevelMedianLots of Experience
New Orleans$49,930$66,140$99,220
Baton Rouge$42,650$56,830$78,160
Lafayette$40,670$55,480$80,510

MAINE

Median Salary: 
$62,800
Bottom 10% (Entry Level): $46,400
Top 10% (Lots of Experience): $85,900

2014-2024 Job Growth: 11%
Projected Annual Job Openings: 510

SALARY BY METRO AREA:

CityEntry LevelMedianLots of Experience
Portland$49,850$64,470$91,370
Lewiston$45,100$63,890$78,040

MARYLAND

Median Salary: 
$72,100
Bottom 10% (Entry Level): $53,400
Top 10% (Lots of Experience): $97,500

2014-2024 Job Growth: 20%
Projected Annual Job Openings: 3,250

SALARY BY METRO AREA:

CityEntry LevelMedianLots of Experience
Baltimore$53,920$72,460$98,440
Frederick$55,480$75,920$98,980

MASSACHUSETTS

Median Salary: 
$83,900
Bottom 10% (Entry Level): $55,200
Top 10% (Lots of Experience): $135,000

2014-2024 Job Growth: 7%
Projected Annual Job Openings: 2,490

SALARY BY METRO AREA:

CityEntry LevelMedianLots of Experience
Boston$60,060$92,190$145,530
Worcester$52,460$82,700$142,480
Springfield$47,590$72,530$101,550

MICHIGAN

Median Salary: 
$65,800
Bottom 10% (Entry Level): $50,600
Top 10% (Lots of Experience): $89,400

2014-2024 Job Growth: 12%
Projected Annual Job Openings: 3,370

SALARY BY METRO AREA:

CityEntry LevelMedianLots of Experience
Detroit$52,500$69,600$105,020
Grand Rapids$48,130$60,180$76,730

MINNESOTA

Median Salary: 
$72,100
Bottom 10% (Entry Level): $49,400
Top 10% (Lots of Experience): $98,400

2014-2024 Job Growth: 12%
Projected Annual Job Openings: 2,010

SALARY BY METRO AREA:

CityEntry LevelMedianLots of Experience
Minneapolis - St. Paul$53,730$77,400$100,460
Rochester$41,210$59,810$94,640

MISSISSIPPI

Median Salary: 
$55,600
Bottom 10% (Entry Level): $40,200
Top 10% (Lots of Experience): $77,500

2014-2024 Job Growth: 14%
Projected Annual Job Openings: 1,070

SALARY BY METRO AREA:

CityEntry LevelMedianLots of Experience
Jackson$42,150$60,990$88,630
Gulfport$42,590$57,050$76,120

MISSOURI

Median Salary: 
$57,800
Bottom 10% (Entry Level): $41,200
Top 10% (Lots of Experience): $80,100

2014-2024 Job Growth: 14%
Projected Annual Job Openings: 2,530

SALARY BY METRO AREA:

CityEntry LevelMedianLots of Experience
St. Louis$42,050$59,020$83,960
Kansas City$44,940$63,260$81,370

MONTANA

Median Salary: 
$60,700
Bottom 10% (Entry Level): $47,300
Top 10% (Lots of Experience): $81,200

2014-2024 Job Growth: 22%
Projected Annual Job Openings: 450

SALARY BY METRO AREA:

CityEntry LevelMedianLots of Experience
Billings$51,200$62,670$88,330
Missoula$50,750$62,420$87,110

NEBRASKA

Median Salary: 
$58,000
Bottom 10% (Entry Level): $42,800
Top 10% (Lots of Experience): $77,600

2014-2024 Job Growth: 14%
Projected Annual Job Openings: 840

SALARY BY METRO AREA:

CityEntry LevelMedianLots of Experience
Omaha$43,460$59,630$80,340
Lincoln$42,500$56,230$75,400

NEVADA

Median Salary: 
$81,400
Bottom 10% (Entry Level): $58,800
Top 10% (Lots of Experience): $104,200

2014-2024 Job Growth: 19%
Projected Annual Job Openings: 860

SALARY BY METRO AREA:

CityEntry LevelMedianLots of Experience
Las Vegas$62,700$84,080$108,390
Reno$55,940$75,620$98,560

NEW HAMPSHIRE

Median Salary: 
$65,400
Bottom 10% (Entry Level): $47,100
Top 10% (Lots of Experience): $93,000

2014-2024 Job Growth: 15%
Projected Annual Job Openings: 490

SALARY BY METRO AREA:

CityEntry LevelMedianLots of Experience
Manchester$46,320$67,900$94,190
Nashua$46,310$63,890$91,400

NEW JERSEY

Median Salary: 
$79,200
Bottom 10% (Entry Level): $57,200
Top 10% (Lots of Experience): $102,900

2014-2024 Job Growth: 13%
Projected Annual Job Openings: 3,000

SALARY BY METRO AREA:

CityEntry LevelMedianLots of Experience
Newark$58,110$81,250$104,130
Trenton$52,450$71,710$93,130

NEW MEXICO

Median Salary: 
$64,700
Bottom 10% (Entry Level): $50,800
Top 10% (Lots of Experience): $87,100

2014-2024 Job Growth: 17%
Projected Annual Job Openings: 660

SALARY BY METRO AREA:

CityEntry LevelMedianLots of Experience
Albuquerque$52,550$66,430$88,630
Las Cruces$27,720$60,700$92,420

NEW YORK

Median Salary: 
$78,000
Bottom 10% (Entry Level): $52,300
Top 10% (Lots of Experience): $111,100

2014-2024 Job Growth: 17%
Projected Annual Job Openings: 7,450

SALARY BY METRO AREA:

CityEntry LevelMedianLots of Experience
New York City$62,140$86,520$116,630
Buffalo$50,970$70,090$93,740
Rochester$46,960$60,760$77,900
Albany$44,640$61,640$79,960

NORTH CAROLINA

Median Salary: 
$58,900
Bottom 10% (Entry Level): $43,300
Top 10% (Lots of Experience): $79,700

2014-2024 Job Growth: 22%
Projected Annual Job Openings: 4,190

SALARY BY METRO AREA:

CityEntry LevelMedianLots of Experience
Charlotte$44,010$59,750$78,850
Raleigh$44,970$60,090$79,230
Greensboro$43,130$61,120$86,440
Winston - Salem$43,770$58,270$77,490

NORTH DAKOTA

Median Salary: 
$57,900
Bottom 10% (Entry Level): $43,400
Top 10% (Lots of Experience): $75,700

2014-2024 Job Growth: 24%
Projected Annual Job Openings: 400

SALARY BY METRO AREA:

CityEntry LevelMedianLots of Experience
Fargo$43,820$58,380$76,530
Bismarck$43,580$57,070$73,580

OHIO

Median Salary: 
$61,300
Bottom 10% (Entry Level): $47,200
Top 10% (Lots of Experience): $80,100

2014-2024 Job Growth: 14%
Projected Annual Job Openings: 4,830

SALARY BY METRO AREA:

CityEntry LevelMedianLots of Experience
Cleveland$52,280$65,220$80,050
Columbus$46,330$61,330$90,830
Cincinnati$47,490$62,580$81,990
Dayton$48,440$59,850$78,710

OKLAHOMA

Median Salary: 
$58,400
Bottom 10% (Entry Level): $42,700
Top 10% (Lots of Experience): $77,000

2014-2024 Job Growth: 14%
Projected Annual Job Openings: 1,160

SALARY BY METRO AREA:

CityEntry LevelMedianLots of Experience
Oklahoma City$43,130$60,220$78,470
Tulsa$43,630$58,820$76,640

OREGON

Median Salary: 
$85,200
Bottom 10% (Entry Level): $61,000
Top 10% (Lots of Experience): $109,000

2014-2024 Job Growth: 15%
Projected Annual Job Openings: 1,280

SALARY BY METRO AREA:

CityEntry LevelMedianLots of Experience
Portland$58,970$86,940$112,620
Salem$63,450$80,010$103,720

PENNSYLVANIA

Median Salary: 
$65,700
Bottom 10% (Entry Level): $47,200
Top 10% (Lots of Experience): $93,700

2014-2024 Job Growth: 14%
Projected Annual Job Openings: 4,890

SALARY BY METRO AREA:

CityEntry LevelMedianLots of Experience
Philadelphia$53,320$76,110$100,010
Pittsburgh$47,760$61,520$80,320
Harrisburg$51,160$64,360$92,930
Allentown$51,170$63,980$86,160

RHODE ISLAND

Median Salary: 
$76,300
Bottom 10% (Entry Level): $55,400
Top 10% (Lots of Experience): $98,000

2014-2024 Job Growth: 12%
Projected Annual Job Openings: 450

SALARY BY METRO AREA:

CityEntry LevelMedianLots of Experience
Providence$55,000$76,050$99,370

SOUTH CAROLINA

Median Salary: 
$59,300
Bottom 10% (Entry Level): $42,200
Top 10% (Lots of Experience): $80,100

2014-2024 Job Growth: 15%
Projected Annual Job Openings: 1,600

SALARY BY METRO AREA:

CityEntry LevelMedianLots of Experience
Greenville$42,380$57,960$77,620
Columbia$33,930$57,080$78,000
Charleston$49,680$65,020$92,470

SOUTH DAKOTA

Median Salary: 
$53,400
Bottom 10% (Entry Level): $41,000
Top 10% (Lots of Experience): $74,700

2014-2024 Job Growth: 12%
Projected Annual Job Openings: 420

SALARY BY METRO AREA:

CityEntry LevelMedianLots of Experience
Rapid City$42,750$57,830$75,800

TENNESSEE

Median Salary: 
$56,800
Bottom 10% (Entry Level): $41,800
Top 10% (Lots of Experience): $76,300

2014-2024 Job Growth: 25%
Projected Annual Job Openings: 2,440

SALARY BY METRO AREA:

CityEntry LevelMedianLots of Experience
Nashville$41,930$58,810$78,640
Memphis$46,000$60,500$78,810
Knoxville$40,920$54,240$70,650
Chattanooga$41,680$56,130$74,340

TEXAS

Median Salary: 
$68,600
Bottom 10% (Entry Level): $50,100
Top 10% (Lots of Experience): $95,000

2014-2024 Job Growth: 31%
Projected Annual Job Openings: 10,820

SALARY BY METRO AREA:

CityEntry LevelMedianLots of Experience
Dallas - Ft. Worth$52,170$71,920$96,640
Houston$55,040$76,670$98,900
San Antonio$45,920$65,450$89,960
Austin$51,570$66,340$86,640

UTAH

Median Salary: 
$59,700
Bottom 10% (Entry Level): $44,200
Top 10% (Lots of Experience): $79,200

2014-2024 Job Growth: 33%
Projected Annual Job Openings: 1,150

SALARY BY METRO AREA:

CityEntry LevelMedianLots of Experience
Salt Lake City$46,020$61,730$81,490
Ogden$42,940$57,090$76,880

VERMONT

Median Salary: 
$62,800
Bottom 10% (Entry Level): $47,900
Top 10% (Lots of Experience): $91,000

2014-2024 Job Growth: 11%
Projected Annual Job Openings: 230

VIRGINIA

Median Salary: 
$63,600
Bottom 10% (Entry Level): $43,400
Top 10% (Lots of Experience): $90,900

2014-2024 Job Growth: 14%
Projected Annual Job Openings: 2,380

SALARY BY METRO AREA:

CityEntry LevelMedianLots of Experience
Virginia Beach$43,130$61,350$79,450
Richmond$44,170$64,510$85,180

WASHINGTON

Median Salary: 
$77,000
Bottom 10% (Entry Level): $52,900
Top 10% (Lots of Experience): $110,000

2014-2024 Job Growth: 20%
Projected Annual Job Openings: 2,470

SALARY BY METRO AREA:

CityEntry LevelMedianLots of Experience
Seattle$55,410$80,960$113,850
Spokane$50,630$73,400$104,950

WEST VIRGINIA

Median Salary: 
$56,700
Bottom 10% (Entry Level): $40,500
Top 10% (Lots of Experience): $78,400

2014-2024 Job Growth: 8%
Projected Annual Job Openings: 590

SALARY BY METRO AREA:

CityEntry LevelMedianLots of Experience
Huntington$39,560$55,600$76,120
Charleston$41,380$55,920$75,860

WISCONSIN

Median Salary: 
$65,100
Bottom 10% (Entry Level): $49,900
Top 10% (Lots of Experience): $90,000

2014-2024 Job Growth: 10%
Projected Annual Job Openings: 1,860

SALARY BY METRO AREA:

CityEntry LevelMedianLots of Experience
Milwaukee$51,600$67,980$91,900
Madison$54,670$73,910$100,370

WYOMING

Median Salary: 
$60,800
Bottom 10% (Entry Level): $44,000
Top 10% (Lots of Experience): $81,000

2014-2024 Job Growth: 20%
Projected Annual Job Openings: 210

SALARY BY METRO AREA:

CityEntry LevelMedianLots of Experience
Cheyenne$47,920$64,100$88,730
Casper$40,880$57,560$77,510

According to the US Department of Labor, registered nurses earn a median annual salary of about $67,490, and most make between $46,360 and $101,630. Entry-level UR nurses often make less than those in direct patient care roles and have fewer opportunities to earn overtime. However, salaries are increasing as the value of the profession is recognized.

Employment of RNs is expected to grow by 16% between 2014 and 2024, according to the US Department of Labor. This is considerably faster than the average for all occupations.

Recent US health care reform efforts aim to improve health care quality while containing costs. This will likely create many UR positions for nurses in the near future, especially within insurance companies and government agencies.

Compare Salaries by City

New York City NY Median Pay

$86520 Per Year

$41.59 Per Hour

Los Angeles CA Median Pay

$95940 Per Year

$46.12 Per Hour

Steps to Become a Utilization Review Nurse

1

Earn an undergraduate degree or practical nurse diploma/certificate.

Almost all utilization review nurses are certified as registered nurses (RNs), having earned either an associate degree or the Bachelor of Science in Nursing (BSN). Many colleges and universities offer four-year educational programs to prepare candidates for RN licensure. The associate degree path, by contrast, requires generally two or three years. Many insurance industry positions are open to AD-RNs, so you don’t necessarily need to hold a BSN.

Show Me Schools »

RN programs include extensive clinical experience in a variety of health care settings. Few of these programs provide specific training in utilization review, although some nursing theory courses cover the basics.

If your goal is to become an LPN, you will enroll a one- or two-year certificate/diploma program rather than a degree program.

2

Become licensed as an RN and pass the NCLEX exam.

In most cases, UR nurses are licensed as RNs by the state in which they practice. This requires a degree from a state-approved program and passage of the NCLEX exam. Aspiring PNs also must become licensed by taking the NCLEX-PN exam.

3

Consider certification options.

Registered nurses may pursue voluntary certification in this specialty through the American Board of Quality Assurance and Utilization Review Physicians. Candidates must meet educational requirements and pass a knowledge exam.

If you’re interested in becoming a certified case manager, or CCM, visit the Commission for Case Manager Certification. Certification can improve your job prospects and compensation.

No special certification is necessary to begin working in utilization management in the insurance industry; employers will train you in the decision-making tools required, or pay for your training elsewhere.

4

Gain care experience.

Many employers require UR nurses to have at least two years of acute care experience. This allows them to develop the clinical judgment necessary to manage patient care in a safe and effective manner.

This acute care experience isn’t always required, though. Utilization management is a key part of the health insurance industry, and insurance providers staff large numbers of RNs and LPNs in these positions (UM consultants and managerial associates). An interested applicant will need a solid history of nursing practice, typically 3-5 years of clinical practice, but this need not be in acute care; RNs with certain types of acute care experience, particularly in critical care, may be employable as UM consultants after only 1-2 years of hospital practice. Providers prefer applicants with experience in managed care.

5

Participate in on-the-job training.

Newly hired UR nurses receive about six months of mentoring and on-the-job training through their employers before working independently.

6

Earn your continuing education credits.

RNs must engage in continuing education throughout their careers in order to maintain their credentials.

7

Look into advancement opportunities.

UR nurses have ample opportunities to advance into management and executive positions within their companies and organizations. Experience increases opportunities for advancement, as does holding a degree in business or health care administration.

As a nurse, it’s unlikely that you would pursue graduate training with the idea of specializing in utilization review, because advanced nursing expertise is not required in this area. However, graduate-prepared nurses may find that aspects of insurance industry UR/UM work, including the possibility of working from home, become attractive over time. In hospital settings, utilization review positions may be held by APRNs who have spent years in practice.

Explore Educational Paths

Students who graduate with a bachelor’s or associate degree in nursing are eligible to become RNs, while students who earn practical/vocational nursing (PN/VN) degrees can obtain LPN/LVN licensure. Your nursing program’s website should indicate that the program is accredited either by the CCNE (Collegiate Council of Nursing Education) or ACEN (Accreditation Commission for Education in Nursing); make sure of this before you enroll, because you’ll find it hard to locate work if you don’t graduate from a nationally accredited nursing program.

Show Me Schools »

CERTIFICATE OR DIPLOMA PROGRAM

1.5-2 years initial study

Practical/vocational nurses care for patients in a range of primary-care settings, such as neighborhood health and outpatient clinics, home care, and long-term care; some hospitals also employ LPNs, who work under the supervision of RNs. PN certificate or diploma programs are offered on a part-time and full-time basis at smaller colleges. Students who graduate are prepared to take the NCLEX-PN and earn their license.

Your PN coursework will include classes such as:

Foundations of nursing

Basic nursing skills, including supportive communication.

Clinical skills lab

Safely put classroom knowledge into practice, with advice from your instructor.

Patient assessment

Learn how to record a patient’s history, check vital signs, and document health.

Principles and practice of intravenous therapy

Learn how to safely initiate and monitor IV therapies.

ASSOCIATE DEGREE

2-3 years initial study

AND/ASN programs are two-year nursing degree programs that prepare students for the RN-NCLEX, and hospital (acute care) practice. You can find these programs at community and regional colleges. Good ADN programs produce graduates who are heavily recruited by local healthcare. If you think that a two-year degree is right for you, do your homework and pick a program that’s well respected, and whose graduates find good employment (programs usually advertise their graduates’ success online and in print).

Some of the courses you’ll encounter include:

Principles of nursing (2+ semesters)

Students develop basic nursing skills in the classroom and in lab.

Nursing care of the acute patient

After completion of introductory classes, students begin studying hospital nursing techniques, and practice their skills in clinical settings.

Nursing care across the lifespan

Students examine the processes that distinguish successive stages in human development.

Gerontology

Students study physical/psychological changes that occur as people advance in age.

BACHELOR'S DEGREE

4 years

A bachelor’s (baccalaureate) nursing program prepares you for the NCLEX_RN, while also encouraging you to become a well-rounded learner. Students take courses in the humanities, improve their writing abilities, and complete coursework in math and the natural sciences. During the first two years of the program, students complete most of their humanities requirements and a number of science prerequisites, including physiology, microbiology, and chemistry. In their second two years, they focus on nursing studies.

Your nursing degree coursework will likely include:

Nursing practice (2+ semesters, with clinical practicum)

Introductory clinical theory and practice.

Acute and chronic care

Building on foundational skills, students nurses expand their skill-set of hospital techniques.

Psychiatric/mental health nursing

Students examine the history and ethics of mental health treatment, study current theory, and have opportunities to practice their clinical skills.

Childbearing and family health

In-depth introduction to care of women and infants in the perinatal period.

MASTER'S OR DOCTORAL DEGREE

2 years, MSN, full-time; 2.5-3 years, DNP, full-time

RNs interested in leadership, nursing education, and a broader scope of practice should consider graduate school. Earning a master’s (MSN) or doctorate in nursing practice (DNP) can prepare you for any of a number of APRN licensures, including nurse midwife and nurse practitioner. An APRN with special interest in education and cutting-edge clinical practice can earn further certification as a clinical nurse specialist (CNS) in a particular area of practice. You will need a BSN in order to apply to a graduate nursing program; other entrance requirements will depend on the specialty area you’re pursuing.

Most APRN coursework includes the following (or similar) classes:

Advanced health assessment

Students refine their diagnostic technique.

Advanced pathophysiology

Students learn more about the physiological changes that underlie visible/measurable disease symptoms.

Advanced pharmacology

Prescriptive knowledge of commonly used medications.

Leadership for health professionals

Students prepare for roles in hospital/clinical leadership by practicing effective communication skills, and learning more about health policy and finance.

Keys to Success in UR Nursing

Necessary Skills and Qualities

Focused

While UR nursing is not as physically demanding as caring for patients on the hospital floor, the work requires other kinds of stamina. These professionals must be able to sit for long periods of time and focus on complicated tasks.

Detail-oriented

All nursing positions require strong attention to detail.

Strong decision-maker

Decision-making skills are essential. Diplomacy and objectivity are also valuable qualities, since UR nurses sometimes face difficult decisions when balancing patient care against cost.

Team player

UR nurses work closely with physicians, nurses, health care providers, patients, family members and insurance company personnel.

Good communicator

Success in this domain requires excellent communication and interpersonal skills. An excellent phone presence is necessary.

Holli Sowerby, EdD, RN

Holli Sowerby EdD, RN is an assistant professor of nursing at Weber State University. Her research interests include the perceptions of graduates regarding laboratory simulation experiences and the effectiveness of simulation.

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