How to Become a Utilization Review Nurse
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 the care they need without burdening the health care system with unnecessary procedures, ineffective treatments or overlong hospital stays. Utilization review nurses also help insureds 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.
Utilization review is a relatively new idea that since the 1980s has evolved 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 well-being 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.
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.
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.
Almost all utilization review nurses are certified as registered nurses (RNs), and most hold a Bachelor of Science in Nursing (BSN). Many colleges and universities offer four-year training programs to prepare candidates for RN licensure. Few of these programs provide specific training in utilization review, although some nursing theory courses cover the basics.
RN training programs include extensive clinical experience in a variety of health care settings. Most 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. Newly hired utilization review nurses receive about six months of mentoring and on-the-job training through their employers before working independently.
In most cases, utilization review nurses are licensed as RNs by the state in which they practice. This requires a degree from a state-approved training program and passage of the NCLEX exam. RNs must engage in continuing education throughout their careers in order to maintain their credentials.
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.
Necessary Skills and Qualities
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. An excellent phone presence, attention to detail and decision-making skills are also essential.
UR nurses are team players who work closely with physicians, nurses, health care providers, patients, family members and insurance company personnel. Success in this domain requires excellent communication and interpersonal skills. Diplomacy and objectivity are also valuable qualities, as UR nurses sometimes face difficult decisions when balancing patient care against cost.
Opportunities for Advancement
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.
According to the US Department of Labor, registered nurses earned a median annual salary of about $65,000 in 2010, and most made between $44,000 and $95,000. 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 26 percent between 2010 and 2020, according to the US Department of Labor. This is considered much 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.