Utilization Review Nurse

If you are interested in the medical field, there are a lot of opportunities waiting for you, and one of them is to be a Utilization Review Nurse.

This profession may be new to some since it is a relatively new idea that has only evolved since the 1980s, together with the concept of managed care.

Employing the skills of a Utilization Review Nurse may help patients make an informed decision in their own health care. Let’s look closely at what a Utilization Review Nurse does.

Utilization Review Nurse: Job Description

It has been said that the profession as a Utilization Review Nurse is a relatively new job, so its job description may not be known to all.

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One of the basic roles of a Utilization Review nurse includes making sure that the health care services being administered to the patients are of the highest quality, and at the same time are cost-efficient and in compliance with the current regulations. They do this by means of the continuous review and audit of the patient’s treatment file. A Utilization Review Nurse is capable of preventing unnecessary procedures, ineffective treatment, and unnecessary extensive hospital stays that may burden the healthcare system.

From the patient’s side, a Utilization Nurse may aid the insured person with conducting an informed decision regarding their health care through proper education regarding the benefits and limitations of their health care coverage.

How to be a Utilization Review Nurse?

Now, if you think becoming a Utilization Review Nurse is a good fit, the minimum credential and the first thing that you need to acquire is to be a licensed registered nurse. It is helpful to have a good base in the general nursing experience in the medical-surgical nursing field.

Most employers require a bachelor’s degree in nursing rather than an associate degree.

Employers may sometimes require specific certification in connection with the job description such as a Utilization review or Risk management certification.

In terms of skills: good communication skills, attention to detail, and the ability to excel under pressure while having minimal supervision are required to have a successful Utilization Review Nurse Career.

Certifications Needed

As stated above, to begin a career as a Utilization Review Nurse, one must start by earning a bachelor’s degree in nursing and have successfully completed the RN licensing requirements and exams in their state.

After passing said licensure exam, they may pursue certifications in healthcare risk management or case management. 

These certification programs in connection with health care risk management or case management would drastically improve the knowledge of those who already have experience in the field of healthcare; it would introduce them to the basic concepts, techniques, and the overall purpose of health assessment management.

The students aiming to acquire these certifications would learn the in-and-outs of improving the quality assessment reporting through defining and describing utilization review plans; this includes gaining working knowledge in filing and reporting of case management claims.

Utilization Review Nurse salary

Based on the study by the US Department of Labor, registered nurses are capable of earning a median annual salary of $67,490, and most of them make between $46,360- $101,630. 

Entry-level Utilization Review nurses often make less compared to those who are in the business of direct patient care roles, but at the same time, they have fewer opportunities to earn overtime for work.

It is worth noting that nowadays, their salary is continuously increasing because the value and need of their profession is also being recognized.

Health care reforms are aiming to improve the health care system by means of targeting quality while containing costs; it is only logical to expect that the demand for Utilization Review Nurses would also increase especially from the side of insurance companies and government agencies.

Roles and Responsibilities

The roles and responsibilities of a Utilization Review Nurse include maintaining a concurrent review of the patient’s clinical information for the purpose of efficiency and maintaining an accurate record of all patient-related interactions.

Also, a Utilization Review Nurse is responsible for coordinating with the health care team regarding the patient’s discharge planning needs.

One of the basic skills required is the ability to stay organized and to interact well with others in any given circumstance because the job entails an ongoing review or pre-certification requests for medical necessity, preparation of the monthly patient management and cost savings report, and to provide the manager of Utilization Management for review with the daily updates needed.

In general, a Utilization Review Nurse must employ the use of knowledge, critical thinking, and skills in order to advocate high-quality care for the enhancement of life, prevent complications during the stay in the hospital, and to decrease the said stay if necessary.

Frequently asked questions:

What is a Utilization Nurse?

A Utilization Nurse works behind the scenes in order to maximize the quality and cost-efficiency of health care services. They ensure that the health care services are administered with quality, cost efficiency, and are complying with the set regulations.

What does a Utilization Nurse do?

Through regular reviews and audits, they make sure that the patients receive the necessary care needed without further burdening the health care system with unnecessary procedures, ineffective treatments, or overlong stay in the hospitals.

Is utilization review the same as case management?

Utilization review and case management are two roles that are distinct from each other, yet they have complementary functions and responsibilities in the healthcare delivery system.

A Utilization Review Nurse if focused primarily on using established review criteria to ensure appropriate utilization of health resources, while case management is focused on the assessment, planning, and coordination of services for patients who are in dire need of continuing assistance.

What are the types of utilization review?

Utilization Review has three types of assessments, which are prospective, concurrent, and retrospective.

Prospective is before the service is performed, concurrent is during the performance of the services, and retrospective is after the service is performed.

How much do utilization review nurses make?

Entry-level Utilization Review Nurses make less compared to those who are in direct patient care roles.

Since the importance of the profession is being recognized, in the future, the demand for Utilization Review Nurses would increase that would also entail higher pay.

What are the responsibilities of a utilization review nurse?

Generally, the responsibilities of a Utilization Review Nurse include the employment of the effective use of knowledge, critical thinking, and skills to advocate quality health care that would enhance the quality of life, prevent patient complications during the hospital stay, and advocate the decrease in the hospital stay if applicable. 

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