How to Become a Utilization Review Nurse

By: Holli Sowerby, EdD, RN

Last Updated: Dec 22, 2018

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.

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

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.

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.

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.

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.

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.

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.

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

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

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.

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.

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:

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:

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:

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: