Review Nurse

Review Nurse
By
Brittney Wilson, BSN, RN

/ August 11, 2020 July 20, 2020
Brittney Wilson, BSN, RN, a bachelors-prepared registered nurse, is the founder and owner of The Nerdy Nurse® and TheNerdyNurse.com. She is the co-founder of Health Media Academy and is an award-winning author and blogger, international keynote speaker, and influencer in the nursing and healthcare technology communities. Brittney is the author of The Nerdy Nurse's Guide to Technology and co-author of The Nurse's Guide to Blogging . She blogs about nursing, technology, health IT, at other healthcare topics at thenerdynurse.com .
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Brittney Wilson, BSN, RN, is a Registered Nurse and founder of The Nerdy Nurse®️. [Read More]

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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.
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.
One of the basic roles of a Utilization Review nurse includes making sure that the health care services are being administered to the patients in the highest quality yet at the same time cost-efficient and is 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.
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 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 having minimal supervision is required to have a successful Utilization Review Nurse Career.
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.
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 working knowledge in filing and reporting of the case management claims.
Based on the study of 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, 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.
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 in coordinating with the health care team regarding the patient’s discharge planning needs.
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.
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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.
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.
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.
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.
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.
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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Advancing Your Career | Career & Finances
Could Utilization Review Be Right for You?
Utilization review nurse (UR) is a non – bedside career option that many nurses enjoy doing .  U R nurses review medical records and make sure patients receive appropriate and quality care while keeping healthcare cost down . They do so by using evidence-based criteria , nursing judgement , and interprofessional collaboration . Let’s explore UR and see if it’s right for you.

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Most likely, you’ve heard of a “UR nurse” or “UM (utilization management) nurse” and wondered what these nurses do exactly. Well, you’re in good company! I’m a UR nurse and I’m going to explain.
It’s no secret that healthcare cost in the United States has been on the rise for many years now. To try to control costs and reduce overuse or misuse of medical services (like inpatient hospital stay, tests, surgeries, etc.), the government passed a law as part of the Social Security Act that required healthcare providers to justify medical services.
To comply with this law, hospitals started employing nurses to review for the appropriateness of inpatient admissions and to determine if the number of days a patient remains in the hospital is appropriate and necessary; hence, utilization review was created.
The goal of UR is to avoid burdening the healthcare system with unnecessary hospitalizations and procedures, all while ensuring that patients receive appropriate and evidence-based care.
Private health insurance companies loved the concept of UR so much that they started implementing it on their end by hiring nurses to review prior authorization requests and claims, received from healthcare providers, for appropriateness.
Some people use the acronyms UR and UM interchangeably, but there is a difference.
UM is a program that a healthcare system has in place to ensure that patient care – from pre-admission to discharge – is medically necessary and cost-efficient. Think of UM as a big umbrella.
Underneath this umbrella, you’ll find smaller umbrellas (subdepartments) such as case management and UR. UR is the actual process of reviewing services for medical necessity. Essentially, UR is a part of an entity’s UM program.
To determine if a medical service is appropriate, the UR nurse reviews the clinical documentation then cross-references with evidence-based, nationally recognized guidelines.
Some of these guidelines are Milliman ( MCG ), InterQual , National Comprehensive Cancer Network ( NCCN ), American Society of Addiction Medicine ( ASAM ). In addition to using the guidelines, UR nurses also use their nursing judgement and confer with a medical director or physician reviewer, if necessary, to decide whether a service is clinically indicated.
You may have deduced by now that there are at least two types of UR nurses: UR nurses who work for healthcare facilities (including hospitals, inpatient rehabilitation, behavioral health, and other levels of care) and UR nurses who work for insurance companies.
A utilization review nurse at a facility is generally responsible to:
A utilization review nurse at insurance companies are on the receiving end and generally:
Keep in mind the above listed responsibilities are not all-inclusive and will vary depending on the employer.
Glad you asked! This varies depending on the setting (clinical vs. insurance), but the most common qualifications include:
According to Salary.com , as of June 2022, the annual salary of a UR nurse in the United States is between $76,200 and $94,700.
Ready to go beyond the bedside? Keeping in mind the minimum qualifications above, you can check job boards for openings. You can check the website of hospitals, long term care facilities, skilled nursing facilities, home health companies for UR nurse opportunities.
If you’re interested in working on the insurance’s side, check for job openings (sometimes called “UM Nurse Consultant”) with major health plans and other payors.
If you need a change and have been sniffing around for non-bedside nursing opportunities, becoming a Utilization Review Nurse may be the answer.
By becoming a utilization review nurse, you can employ your nursing knowledge, experience, and critical thinking skills to continue to advocate for patients.
UR also affords you the opportunity to gain new knowledge, understand and navigate the insurance industry, obtain additional certification while offering you ample opportunities for career advancement.
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