What Is a Utilization Review Nurse?
Utilization review (UR) is a crucial aspect of healthcare, and it wouldn’t be the same without the dedicated work of a utilization review nurse. Below, we explain utilization reviews, where these nurses fit in this process, their salary, and more.
What Is Utilization Review and Why Is it Important?
Utilization reviews are all about effectiveness and efficiency. They ensure that healthcare services are appropriately applied to the patient and their unique situation and that materials are being allocated with cost-effectiveness in mind. This process promotes quality care for the patient in a way that’s economical for the facility.
The government requires hospitals to conduct utilization reviews in order to participate in Medicare and Medicaid. The review process is also uniquely applied to pharmaceuticals to avoid the misuse of opioids.
Who Conducts Utilization Reviews?
A variety of entities conduct utilization reviews. They can include:
- Hospitals
- Insurance companies
- Home health companies
- Nursing homes
- Post-acute care facilities
How Does the Utilization Review Process Work?
There are three main types of utilization reviews: prior authorization, concurrent, and retrospective. Concurrent reviews occur while the patient is receiving healthcare services. Retrospective reviews occur after the patient has completed their care.
Utilization reviews can also be done as a part of the prior authorization process by health insurance companies to approve patients for a procedure. These reviews are often conducted by nurses employed at the facility, who follow protocols defining high-quality care.
What Is a Utilization Review Nurse and What Does a Utilization Review Nurse Do?
A UR nurse decides whether or not a patient is receiving the appropriate level of care, and whether resources are being used efficiently. They also assess the cost effectiveness of care to ensure the balance between patients receiving proper care while minimizing costs for the facility.
Along with following the UR protocols, these nurses work closely with insurance companies, quality-improvement teams, social work departments, and the staff responsible for the patient’s care to assess whether the desired standards are being met. UR nurse tasks can include:
- Checking medical records
- Speaking with patients regarding care
- Speaking with the healthcare team and insurance companies regarding care
- Investigating misuse of resources and costs that appear abnormally high
- Making recommendations based on findings
- Assisting with patient discharge to ensure a smooth transition home or to another facility
- Assisting with determining whether or not a treatment will be reimbursed by insurance
How to Become a Utilization Review Nurse
If you’re interested in this specialty, you may wonder how to enter this field. The steps to becoming a UR nurse are outlined below:
- Obtain your BSN by successfully completing nursing school.
- Pass the NCLEX-RN.
- Obtain hands-on clinical experience.
- Ideally, obtain case management experience.
- Create a strong utilization review nurse resume and apply to jobs.
Utilization Review Nurse Certification
Obtaining a certification is far more than an advantage in the job search — it shows your commitment to the field. It also helps you gain in-depth knowledge that’s up to date with best practices. Here are some UR certifications to consider.
- Health Utilization Management Certification (HUMC): Learn about quality-management principles and how they impact the facility’s workflow, develop policies and procedures to improve quality of care, and identify and prioritize areas of improvement. You can also get qualified in the following subspecialties:
- Pre-Review
- Initial Clinical Review
- Clinical Decision Support
- Clinical Review Criteria
- Health Care Quality & Management (HCQM): Ensures the healthcare worker knows the tools and processes required to reduce medical errors, ensure patient safety, reduce unnecessary services, and avoid delays in care. In addition to HCQM, you can get qualified in the following subspecialties:
- Case Management (CHCQM-CM)
- Managed Care (CHCQM-MC)
- Patient Safety and Risk Management (CHCQM-PSRM)
- Transitions of Care (CHCQM-TOC)
- Workers’ Compensation (CHCQM-WC)
Utilization Review Nurse Salary
The average utilization review nurse salary in the U.S. is $89,200 per year. However, these nurses can make between $79,300 and $98,500 per year. Keep in mind that these rates can vary based on location, years of experience, and the specific facility.
Is Becoming a Utilization Review Nurse Right for You?
Whether you want to pursue this path or not, now you know about these nurses and how they relate to you. You can keep this knowledge in mind when you find nursing jobs that work for you through IntelyCare.