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Could Utilization Review Be Right for You?
- Utilization review nurse (UR) is a non–bedside career option that many nurses enjoy doing.
- UR 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.
Overview of Utilization Review
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.
Is It “UR” or “UM”?
Some people use the acronyms UR and UM interchangeably, but there is a difference.
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.
How Does a Utilization Review Nurse Know if Care Is Appropriate?
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.
A Day in the Life of a Utilization Review Nurse
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:
- Examine the medical records to gather an accurate clinical picture of their assigned patients.
- Review the guidelines to determine medical necessity. Is the inpatient admission warranted or should this patient be in observation? Is the patient in the correct level of service (ICU vs. Med/Surg Floor)? Can this stable patient be discharged to a lower level of care?
- Investigate and query healthcare providers as needed to ensure accurate documentation and efficient care.
- Communicate clinical information to the insurance company to facilitate obtaining an authorization for the medical service.
- Inform the insurance company of the patient’s progress for continued stay/concurrent review.
- Collaborate with other disciplines for discharge planning and ensure the most appropriate level of care at discharge.
A utilization review nurse at insurance companies are on the receiving end and generally:
- Evaluate the clinical documentation received from healthcare providers and facilities.
- Review the guidelines to ascertain the appropriateness of care and medical necessity (this often includes inpatient and outpatient services).
- Contact the requesting healthcare provider if additional information is needed.
- Discuss with the physician reviewer who is part of the insurance company’s UR team if the nurse is unable to meet criteria or if a review is challenging.
- Inform the requesting provider of the determination – either certified (approved) or not certified (denied) – and make recommendations for more appropriate alternative services/level of care if necessary.
- Answer questions from patients and providers about unfavorable decisions (when services are denied because they are not medically necessary per guidelines).
Keep in mind the above listed responsibilities are not all-inclusive and will vary depending on the employer.
Qualifications of a Utilization Review Nurse
Glad you asked! This varies depending on the setting (clinical vs. insurance), but the most common qualifications include:
- Being a registered nurse with an active license – a Bachelor of Science degree is often preferred. In some facilities, licensed practical nurses, social workers, occupational, or physical therapists can also do UR work.
- A minimum of 2 years of acute care clinical experience.
- Excellent critical thinking skills.
- Solid communication skills.
- Attention to detail.
Other Points to Consider:
- Willingness to obtain a Utilization Review Certification if required by your employer.
- Being inquisitive and asking pertinent questions.
- Understanding of how insurance works.
- Basic understanding of diagnosis codes (ICD-10), procedures codes (CPT), diagnosis-related group (DRG).
- Ability to learn how to use the evidence-based criteria.
- Willingness to learn the UR process (Yes, much like the nursing process, there is such a thing as a UR process!).
- Being able to make difficult decisions.
Weighing the Pros and Cons
How to Get Started?
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.
The Bottom Line
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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