Introduction

Utilization management (UM) began in the 1970s and increased in popularity in the 1980s due to rising healthcare costs, leading to a desire among insurers and employers to control these costs (9). UM evaluates the effectiveness of treatment for each patient before, during, and after medical services are received. Improving patient care and the overall health of the population are also goals of UM. The final goal of UM is to reduce insurance claim denials (9).

Utilization management nurses are LPNs, RNs, and APRNs who work in various healthcare settings and focus on ensuring that patient care is delivered most cost-effectively without duplicating services (2). The settings include hospitals, private practices, government agencies, residential facilities, and insurance companies. The goal of the UM nurse is to maximize the quality of patient care cost-effectively (10).

UM is not a bedside role, yet it requires extensive clinical nursing knowledge obtained from a nursing degree and certifications (2). Most UM nurses work “desk hours” from Monday to Friday, eight to ten hours daily, managing a quota of cases (6, 7). Some facilities may require UM nurses to work occasional holidays and weekends and be on call after hours, but this is rare (7).

UM nurses who work in hospitals have interactions with patients and families and thus are required to communicate therapeutically, set appropriate boundaries, and demonstrate appropriate compassion. These nurses must also be comfortable collaborating with physicians and other healthcare team members and presenting information to facility administrators.

UM nurses conduct systemic reviews, called utilization reviews (UR), of the patient’s medical records and gather pertinent details from the healthcare interdisciplinary team members. This data collection can equip them to make recommendations about which services are most appropriate for the patient and ensure that insurance companies pay for the services provided (10).

Utilization management differs from case management (CM) in that UM focuses on the medical necessity of care and treatment services, ensuring that patients receive only those pertinent to their condition. Case managers take a holistic approach to patient care and consider all aspects of the patient’s situation to ensure they receive the best-coordinated care possible (10).

The demand for UM nurses is increasing, and the job outlook in this specialty is excellent, especially since healthcare organizations are committed to reducing costs while improving patient outcomes. Health reform continues to generate a need for utilization management nurses since patients receive the appropriate care at the proper time, while managing costs is the goal of all healthcare organizations (7).

As the healthcare landscape changes and evolves, UM nurses are needed to help advocate for patients (7). The Patient Protection and Affordable Care Act (PPACA) has increased the number of Americans with health insurance coverage, which increases the demand for health services. UM nurses are necessary to ensure that these services are delivered as cost-effectively as possible (7).

The demand for this specialty is expected to grow by 12% between 2018 and 2028, creating almost 400,000 new jobs in the United States (10). The average utilization management nurse’s salary in the United States is $90K, with overtime earnings adding $10K annually (10). The highest-paying states for utilization management are (in order of highest to lowest paying): California, Hawaii, Oregon, Massachusetts, Alaska, Washington, New York, New Jersey, Nevada, and Connecticut (7, 10).

Other names that describe utilization management nurses are nurse reviewers, clinical reviewers, clinical resource coordinators, and clinical care coordinators (6). The top resources for nurses who want more information about the utilization management nurse’s role are the American Association of Managed Care Nurses and the American Nurses Association (7).

Utilization Management Process and Steps

Utilization management is a process that evaluates the efficiency, appropriateness, and medical necessity of treatments, services, procedures, and facilities provided to patients on a case-by-case basis (9). The process affects hospitals and other health facilities, healthcare staff, insurers, and patients, and it is on behalf of or supported by purchasers of medical services (insurance companies) (9).

Utilization management programs must meet all applicable state and federal insurance guidelines and requirements and regulations set forth by health plans and third-party payors, such as the Inpatient Prospective Payment System. Specialty medical society guidelines must also be considered for primary care, pharmacy, advanced care, emergency, behavioral health, psychiatry, substance abuse, and surgical services.

Facilities that receive reimbursement from the Centers for Medicare and Medicaid Services (CMS) must have a plan for reviewing services provided by the facility and its clinicians (9). Most facilities seeking reimbursement from CMS run utilization management daily on all cases and consistently ensure accurate clinician documentation of patient services. Documentation includes everything from vital sign measurements to medication administration and effectiveness to detailed treatment plans (9).

Employers in the United States mainly provide health insurance, and therefore, the private sector pays for the healthcare of most people under age 65. Because of this, companies that insure their employees assume the financial risk of these employees and their dependents. Utilization management benefits patients by offering more effective treatments at lower costs with fewer claim denials.

Healthcare providers benefit in similar ways: fewer claim denials, lower costs, more effective treatments, improved data, and better resource deployment. Insurers benefit in these same ways, as well, as they receive better data to evaluate the effectiveness of new treatments and protocols (9).

Medical data that is tracked by UM teams includes (9):

• Inpatient hospital admissions
• Skilled Nursing Facility (SNF) admissions
• Hospital and SNF inpatient days
• Emergency department visits
• Home health visits
• Outpatient visits
• Primary care physician visits
• Specialty referrals
• Diagnostic tests
• Cost per visit

This data is typically tracked per thousand patients monthly or yearly (9). The utilization review process helps the utilization management nurse track patient progress and healthcare costs.

There are three types of reviews that UM nurses conduct (5, 7, 9):

Prospective Review: This requires analyzing the patient’s proposed treatment plan to eliminate unnecessary, ineffective, and duplicated services. This type of review occurs during urgent and routine referrals before the patient’s treatment begins. Other terms to describe this review are precertification, preadmission certification, admission certification, prior authorization, preservice review, and pre-procedure review.

This initial review aims to control the process and ensure that the requested clinical service is necessary and that it will be delivered in the appropriate setting. National standards of care and clinical criteria help determine the appropriateness of the request.

This step helps contain costs and facilitates communication within the healthcare organization about the patient and the services to be received, encouraging more effective care coordination for the patient.

Concurrent Review: This occurs while the patient’s treatment is in effect and starts within 24-72 hours of admission to a hospital (9). This review includes care coordination, discharge planning, and care transition. Its purpose is to track the utilization of resources and the patient’s progress to reduce potential denials of coverage by insurance companies after treatment is completed.

Other goals include ensuring efficient and effective care, reducing the misuse of inpatient services, and promoting safe, high-quality patient care. Like the prospective review, the concurrent review facilitates interdisciplinary team communication, quality patient monitoring, and support transitions to the next appropriate level of care. Patients who could benefit from case management, disease management, or health strategies for their specific clinical situation are identified. Also, as in the prospective review, national standards of care and clinical criteria are utilized.

Retrospective Review: This final review occurs after the patient receives treatment and the bill for that care is submitted. The goal of this step is to evaluate the appropriateness, effectiveness, and timing of treatments, as well as the setting in which the services were rendered. It is determined which treatments work best so that they can be applied to similar patients in the future.

The billing codes used to describe the care on the patient’s bill are evaluated according to the Current Procedural Terminology (CPT) and the International Classification of Diseases-10 10 (ICD-10) standards. Only minimal discrepancies should be found during the retrospective review conducted at the end of treatment comparing the concurrent review conducted during treatment to the prospective review conducted before treatment.

The UM nurse determines successes and failures during the retrospective review and shares this data with the healthcare team and institution. If proven treatments are not used for a patient and the insurance company denies the patient’s claim, the healthcare institution (hospital) is financially responsible. The retrospective review ensures that reimbursements are accurate and determines if a claim should be denied.

The steps in the utilization management process are (9):

Prospective Review

• Verify the patient’s coverage and eligibility for the proposed treatment.
• Collect the patient’s clinical data.
• Determine the level of care needed and the necessity of the treatment.
• Approve or deny the treatment according to clinical, institutional, and insurance criteria.
• Appeal the denial, if warranted.

Concurrent Review

• Monitor the patient’s progress, prognosis, cost, and resource usage.
• Send the patient’s clinical progress information to the insurer.
• Approve continuing treatment or request to change treatment.
• Appeal the denial of the change request, if warranted.

Retrospective Review

• The insurer review the patient’s records.
• Insurer updates its criteria for covered treatments.
• Coverage may be denied at this time.
• If denied, the physician or patient can appeal.

The utilization management process is time-consuming and complicated. If a denied claim is appealed, some of the steps may need to be repeated (9).

Utilization Management Benefits and Challenges

As stated previously, one of the main benefits of utilization management is that patients receive the appropriate care at the appropriate time while managing costs (7). An additional benefit of UM programs is that they pinpoint excessive service use that leads to waste within the health care system, which in turn impedes quality (5).

Since the UM process gathers copious amounts of patient and facility data, this information can be used to connect to other support programs, such as disease management, care management, and population health programs, that improve patient outcomes. Collaboration in healthcare delivery, improved quality of care, and increased patient satisfaction are achievable outcomes.

Medically necessary services are expected to produce the intended results for the patient, with benefits outweighing any potential harmful effects (5).

Medically necessary services are the standard of care that patients expect to receive. Healthcare professionals are the key to ensuring that the standard of care and medical necessity remain balanced.

Most UM programs are advised by a committee of physicians and advanced practice nurses from different specialties who evaluate the program’s appropriateness and validity and provide accountability for medical decisions (5). This understanding of medical necessity and the required collaboration between the healthcare and UM teams leads to improved care delivery and patient outcomes (5).

During utilization management, treatment is evaluated and approved during the prospective or concurrent review, which creates fewer reasons to deny claims.

For example, a primary care physician informs a patient that they have a fractured tibia, which requires a referral to a surgeon. The patient contacts their insurance provider with this news, and the insurance provider discusses the situation with the surgeon. Topics explored between the surgeon and insurance provider are whether the procedure should be performed inpatient or outpatient, which pre-surgical tests can be performed, how much time the patient will require to recover, and whether this recovery requires inpatient (hospital stay) or outpatient services (physical therapy), or a combination of both (9).

In another example of utilization management, a hospital admits a patient for management of a heart attack after the patient has been stabilized in the emergency department. The hospital’s UM nurse contacts the patient’s insurance provider to discuss treatment options and optimal length of stay. The insurance provider requires periodic progress reports from the UM nurse to monitor the patient’s care. The cardiologist determines that the patient is not responding to the treatments as anticipated and discusses different treatment options that have shown promise in similar patients with the UM nurse. The insurance company approves the surgeon’s request to implement a different treatment for the patient. This collaboration ensures better outcomes for the patient and more cost-effectiveness.

Physicians are highly motivated to try new treatments for their patients, and each is evaluated for efficacy compared to existing options. Insurance companies cover treatments that are effective in the future, whereas those that are not effective are not covered moving forward. The savings that benefit all parties far outweigh the costs of the facility’s UM program (9).

Insurance companies help to reduce healthcare costs by providing (9):

• Incentives to prescribers who utilize less costly treatments
• Education of healthcare providers about effective practices and care standards
• Patient and family education
• Incentives to patients who opt for less expensive treatments
• Measures to monitor patient referrals to prevent those that are too expensive and require unnecessary specialists
• Contracts with providers who have proven track records of cost containment

Even though utilization management has many benefits, most physicians are critical of the paradigm because they feel that, as healthcare providers, they know what is best for the patient (9). Conversely, insurance companies think they should have the ultimate decision-making rights as payors in the patient’s care. Physicians think utilization management limits their clinical autonomy while adding an intolerable administrative burden to their already stressful role (9).

Additional challenges of utilization management include (9):

• Denial of patient claims can create a financial hardship for patients.
• Patients can incur costs if they are not compliant with the treatment plan.
• Patients can take legal action if coverage or experimental treatment is denied.
• Physicians are more concerned with using their clinical expertise to deliver favorable patient outcomes than with ensuring insurer guidelines are met.
• The number of reviews and claim denials is escalating.
• The UM process is cumbersome and viewed by clinicians as unnecessary “bureaucratic red tape,” especially since healthcare costs continue to rise despite UM. This extra paperwork prevents clinicians from spending time with patients.
• Physicians are not always open to the feedback contained in retrospective reviews.
• The outcomes of the prospective and concurrent reviews can contradict the physician’s wishes.
• De facto denial can occur when the insurance company does not respond to the insurer or issue payment to the medical provider for undisclosed reasons.
• Insurance companies do not agree with the physician’s orders for specific tests and thus deny these claims.
• Best clinical practices and most cost-effective treatments contradict each other, creating more conflict between clinicians and insurance companies.
• Review criteria are not shared with clinicians and patients, so there is no understanding of why some claims are denied.
• Insurance costs fluctuate due to the number of providers and the extent of coverage available.

Insurance companies remain steadfast in the belief that utilization management is an efficient clinical and financial tool. At the same time, many clinicians have lost faith in the process and feel weighed down by the bureaucracy and perceptions that insurance companies care more about their financial bottom lines than patients’ well-being (9).

Legal Aspects of Utilization Management

Several aspects influence the legal concerns of utilization management, such as patient confidentiality, improper conduct, and patient rights. First and foremost, utilization management nurses must understand the Health Insurance Portability and Accountability Act (HIPAA) and their facility’s policies and procedures regarding patient confidentiality (3). The nurse must be clear about with which parties the patient’s information can be shared, how the information may be transmitted, and how and when any potential information breaches must be reported (3).

Additionally, if a payor’s request for information does not adhere to HIPAA policies, the nurse should question this. As a mandatory reporter, the nurse should report to law enforcement any concerns about public health, child and elder abuse, births, and deaths (8). UM nurses must also report improper conduct, such as fraud and waste (8). If the nurse suspects improper conduct, they should report it to their employer and the U.S. Office of the Inspector General (OIG) (1).

Utilization management nurses must also endorse the rights of hospitalized patients, including maintaining a safe environment that is free from exploitation, neglect, and verbal, mental, physical, and sexual abuse. Patient care must be free from discrimination based on age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex or sexual orientation, and gender identity or expression. Patients on a police hold, those admitted to psychiatric units, victims of neglect and abuse, and those who discharge themselves against medical advice (AMA) require special considerations, and the UM nurse must be aware of the laws surrounding these circumstances (1, 8).

When managing denials during a utilization review, the nurse may need to refer the case to a physician advisor. The physician advisor reviews the case and collaborates with the attending physician to determine the patient’s acuity, severity of illness, and level of care required. When a payor denies a patient claim, a notification is sent to the patient and affected providers that provides a denial rationale, subsequent steps, strategies for appealing the denial, payor contact information, and other information required by law. Patients have a legal right to understand why their claim was denied and how to appeal it (1).

Role of the Utilization Management Nurse

The utilization management nurse utilizes their clinical knowledge to assess the patient treatments’ appropriateness, effectiveness, timing, and setting to prevent payment denial and optimize financial reimbursements by insurance companies and other payors (2).

The UM nurse’s six main responsibilities include (2):

• Medical record review
• Treatment plan evaluation
• Healthcare service coordination
• Resource management
• Insurance company collaboration
• Compliance and documentation

The nurse begins the process by reviewing the patient’s treatment plan before commencement to ensure that unnecessary, ineffective, and duplicated services do not occur. The nurse then works with the patient’s insurance company to provide preauthorization information to ensure that the appropriate reimbursement is received and that the patient is not burdened with unnecessary payments (2).

During the patient’s treatment, an ongoing review tracks resource utilization and patient progress to prevent reimbursement denials. The nurse focuses on the patient receiving the best care possible that aligns with established clinical and institutional guidelines, protocols, and available resources. For example, UM nurses decide whether a patient experiencing an infection should be managed as an outpatient or admitted to the hospital.

Suppose this same patient is admitted to the hospital and the infection becomes more acute. In that case, the UM nurse helps decide if the patient requires treatment in a specialized unit, such as the intensive care unit (ICU), or if the patient should be treated in a less costly medical-surgical unit (2).

Due to the rising cost of healthcare services, one of the vital roles of the utilization management nurse is to manage resources (2). The nurse identifies areas where costs can be managed or reduced, such as length of hospital stay, medications, diagnostic tests, and therapies, and communicates these to the other team members. The nurse does this by working collaboratively with other interdisciplinary healthcare team members, such as physicians, nurses, pharmacists, clinical case managers, dieticians, therapists, and administrators. The nurse requests essential information from these team members to confirm the patient’s insurance authorization services (2).

If the payor denies reimbursement, the nurse investigates these claim denials and appeals them to the insurance company (2, 5).

There are myriad reasons why insurers deny coverage, but here are the most common (5, 9):

• Benefit denial/contract exclusion: Benefit denials focus on the patient’s entitlements under the patient’s agreement with the health insurance company. For example, most insurance companies do not cover fertility treatments or aesthetic surgeries, so they would deny these services. Services performed at facilities not in the insurer’s network can also be rejected.
• Medical necessity denial: These focus on the patient’s need for a specific service. For example, a patient sustains a minor head trauma with no signs of complication on the physical exam, but the emergency room physician orders a magnetic resonance imaging (MRI) diagnostic procedure. The insurance company reviews the claim and finds that the MRI was not medically necessary, thus denying the patient’s claim.
• Unproven/investigational treatment denial: Insurance companies often deny services that are deemed unproven or investigational because they do not yet have a track record that validates their efficacy or necessity.
• Documentation error denial: Clinician documentation that includes errors, omissions, or incomplete information can cause insurance companies to deny the claim.

Throughout the entire review process, the nurse ensures that the patient’s records contain accurate and essential documentation of services received, as well as ensuring that the services the patient received adhere to regulatory and accreditation standards. Poor documentation can result in the denial of reimbursement for services from insurance companies, thus financially burdening the patient and healthcare facility (2).

Required Nursing Education and Skills

To become a UM nurse, one must graduate from an accredited nursing school, pass the National Certification Licensure Exam (NCLEX-RN), and obtain a license through the state board of nursing. Most employers prefer nurses with a Bachelor of Science in Nursing (BSN) degree who possess at least two to three years of clinical experience in an acute care setting. Having a Basic Life Support (BLS) certification is also required. A master’s degree is not often needed for UM work, but the additional education can yield higher pay and career advancement opportunities (2, 10).

Employers do not always require certification, but this additional knowledge is preferred. The Case-Management Nurse—Board Certified (CMGT-BC), Health Care Quality & Management (HCQM), and Healthcare Risk Management Certificate (HRM) certifications are the most popular (2, 10). On average, certification courses take three to four months to complete (10).

For nurses who have previously worked in another specialty and who wish to become a UM nurse, the specialty certifications that employers most desire are Certified Case Manager (ACM), Legal Nurse Consultant Certified (LNCC), Certified Managed Care Nurse (CMCN), Certified Nurse Educator (CNE), Family Nurse Practitioner (FNP), Certified Hospice and Palliative Nurse (CHPN), Certified Forensic Nurse (CFN), Critical Care Nurse (CCRN), and Certified Clinical Research Professional (CCRP) (10).

Utilization management nurses possess several essential skills. These include (2, 10):

• Clinical expertise: UM nurses must be familiar with current evidence-based clinical practices, especially in the acute care setting. Strong clinical knowledge is essential to understanding treatments and therapies and comparing them to insurance regulations. Being skilled in evaluating medical data, treatment plans, and patient outcomes is also essential.
• Technological proficiency: Nurses must be confident using technology, such as the electronic health record (EHR), to retrieve and interpret data. Understanding how to use technology to access laboratory results, dietitian records, surgeon’s notes, and the like is imperative. The nurse should also be proficient in using health insurance portals and platforms to review claims and electronic mail to communicate with the interdisciplinary team members and payors.
• Leadership skills: Leading and directing the utilization review staff at a health care organization is a vital role of the utilization management nurse. The nurse must ensure that appropriate staff are trained, policies and procedures are followed, and compliance with the medical and insurance industries is maintained. Deep knowledge of the inner workings of the healthcare industry, types of health insurance available, and how payor systems work is crucial to the utilization management nurse’s success as a leader.
• Critical thinking ability: Utilization management’s foundation is analyzing large amounts of data, organizing records, prioritizing tasks, navigating complex paperwork, and evaluating outcomes. Understanding cost implications is another crucial aspect of the role. UM nurses must possess powerful critical thinking skills to be successful in this specialty.
• Communication skills: Utilizing therapeutic and interpersonal communication skills is essential when communicating with healthcare providers, hospital administrators, and insurance company employees. UM nurses are comfortable using and interpreting medical and legal jargon. These nurses implement their therapeutic communication skills when interacting with patients and families to discuss treatment options and make sure they understand their rights and responsibilities. They must also be comfortable presenting data to upper management and key decision makers.
• Ability to work independently: UM nurses are expected to work independently without much guidance from superiors. These nurses must be self-starters who enjoy working in a fast-paced environment where sound decision-making skills are essential. Some UM nurses work from home, where they must be able to ignore distractions. Like all nurses, UM nurses must be able to stay calm in chaotic situations, set and maintain clear boundaries with patients and families, and maintain a professional demeanor in situations that may involve conflict.
• Relevant knowledge: Nurses should be knowledgeable about healthcare systems, insurance reimbursement guidelines, and industry and facility regulations. This knowledge aids nurses in making informed decisions, maintaining organizational compliance, and executing policies to ensure patients receive quality care during resource utilization.

A UM nurse requires a delicate balance of clinical knowledge, technological savviness, and team collaboration skills.

Pros and Cons of the Utilization Management Nurse Role

Like all careers and jobs, the utilization management nurse role has several positives and negatives.

The table below details these aspects (7).

Being a UM nurse can be stressful because the nurse shoulders tremendous responsibility, including ensuring that the patient receives the appropriate level of care while not receiving care for which they are not eligible. This can lead to frustration while the nurse tries to advocate for patients while adhering to insurance and facility protocols (10).

A Day in the Life of the Utilization Management Nurse

Most UM nurses’ daily schedules include reviewing cases, answering and returning phone calls, and attending meetings and training (6). A typical day may start with a team meeting where all the cases under review are discussed by the UM team and prioritized. Next, the nurse may be required to spend a few hours on the phone addressing calls from patients. Finally, the nurse spends the last hours of the workday completing reviews of the daily quota of cases assigned, typically 30-50 cases (6).

The nurse uses the phone, email, and technology tools like InterQual® to complete tasks. InterQual® is an evidence-based clinical support solution for payors, providers, and government agencies that require clinically appropriate medical utilization decisions (4). McKesson also provides related tools. The nurse also accesses and interprets guidelines from their facility, Medicare, and Milliman Care Guidelines (MCG) to help guide decision-making (6).

The Future of Utilization Management

Utilization management centers around the future because it utilizes the present data to project future trends and costs. During the retrospective review process, if new and experimental treatments are more effective or less expensive than existing ones, they will be moved to the forefront (9).

Trends that affect the future of utilization management are (9):

• There is a need to control costs in the face of inflation, increased manufacturing costs, and the resources required to research and develop pharmaceuticals and biotechnology.
• The increasing costs of other technologies, such as electronic health records and other data storage and retrieval platforms
• The aging population and its drain on societal resources
• Changes in organizational relationships and business practices of health insurance companies, hospitals, and government organizations.
• Political fluctuations and legislative changes affect current healthcare practices and delivery.
• Artificial intelligence’s presence removes the need for human input in some instances.

Case Study

Yosef has worked as a utilization management nurse at a major hospital system in Seattle, Washington for the past three years. Before working in utilization management, Yosef held positions in his employer’s intensive care and medical-surgical departments. He felt burned out on patient care and met with the hospital’s human resources manager to explore other nursing roles within the organization.

The human resources professional told Yosef that the hospital needed utilization management nurses to conduct utilization reviews and that the hospital would train him for the role if he was interested in the position. However, they would require that he obtain his utilization management certification within 12 months of starting the position. The contract for Yosef’s new position lists a starting salary of $115K/year, an increase of $15K/year from Yosef’s previous nursing positions. Josef earned a BSN several years ago, is a CCRN, and holds a BLS certification.

While studying for the utilization management certification, Yosef learned the history of insurance companies in the United States and how they became an integral part of the healthcare industry. He also knows that utilization management was born from the need to contain escalating healthcare costs, and he understands that much of his new role will require him to track the costs of patient procedures.

Yosef finds that he enjoys his new role because it permits him to work from home several days a week. His friends warned him that working from home would be too distracting—that he’d be too tempted to play video games and go to the gym rather than to complete his work—but Yosef discovers that he’s much more focused when working from home. Without the distractions of co-workers and the bustle of the hospital, he can complete his case reviews in just a few hours versus the several hours it takes him to complete the same tasks while working at the hospital. Yosef’s supervisor even comments on his ability to review cases quickly and accurately.

Even though Yosef was burned out doing bedside nursing, he was afraid that his new role would completely remove him from working with patients. Still, he was pleasantly surprised that the utilization management role requires him to speak with patients daily. He can utilize his therapeutic communication techniques to calm patients and let them know he’s on their team. He can also continue teaching patients about their illnesses and how best to manage them. Yosef feels good about connecting with patients in this way and finds that it is much less stressful than when he was on the unit, where he was overwhelmed with too many responsibilities and not enough time to complete them.

Yosef also utilizes his teaching skills by showing the bedside nurses the importance of accurate and frequent charting, especially for Medicare patients. Yosef explains that charting on Medicare patients must cover certain parameters for reimbursement purposes. He even creates charting cheat sheets to help his colleagues better document their patients’ care.

The fast pace of the utilization management nurse role also thrills Yosef because he does not like to be bored. He enjoys having goals and deadlines to meet and feels that the dynamic nature of the work keeps his brain active. He is constantly analyzing data, comparing treatment outcomes, and working with interdisciplinary team members to solve problems. He learns about new procedures and experimental treatments and enjoys asking the hospital’s physicians detailed questions about these treatments. Yosef also likes working with technology and leading meetings with the utilization management and interdisciplinary teams.

The one part of his job that he doesn’t enjoy is when Yosef encounters denied claims, causing him to research why the insurance companies denied these patient claims. The patients and their families get upset with the insurance companies, and the physicians become easily angered when their clinical decisions are questioned. Yosef sometimes feels that he is between a rock and a hard place, and he doesn’t always understand why insurance companies deny some claims and approve others that are very similar. Being a clinician, he also becomes frustrated that patient care boils down to dollars and cents, not necessarily what is best for the patient. He feels like insurance companies make things much more convoluted than they need to, and that they don’t always have the patient’s best interests at heart.

However, Yosef tries to focus on the positive and reminds himself that his role is vital to the industry and that he is still helping patients, it’s just in a way that is a little different from his bedside nursing days.

Conclusion

Utilization management has existed since the 1970s and offers a rewarding career for nurses who wish to work regular business hours without the physical demands of patient bedside care. The nursing specialty of utilization management requires sound clinical judgment, the ability to multitask and work independently with limited oversight from superiors, strong critical thinking skills, and the ability to communicate effectively.

These nurses must be solution-oriented and not be afraid to advocate for patients in the face of adversity. They must also have extensive knowledge of payor systems, clinical finances, and patient confidentiality and rights.