Utilization Review

Specialties Case Management

Published

How does one get started in doing Utilization review? Do you have to have a certificate and where does one get that? I have done floor nursing for many years and need to get off the floor.. Thank you..:yeah:

I have been a psych nurse for approx 30 yrs, the last 5 in forensics. d/t a recent back injury, I cannot continue in psych nursing at the AA degree level which involves direct pt care, including takedowns etc. I never did acute med surg, only acute psych. I'm wondering without the acute med surg experience if I would have a difficult time being hired into any of the following: UR, case management, or MDS. D/t my age, 61, and being out of time and money (1 yr on SdI , ) I am looking for the quickest way to employment, without waiting for advanced training. I don't mind training into a job that will train you on the job or ask you to take some additional certification courses while employed. I just don't see that a long journey to a bachelors and then a masters makeing sense at this time in my life. Of the 3 choices I mentioned which would be the best to start with, and then to progress on to. I see courses for RN to MSN if you want to to case management. Is that really necessary? Bewildered and Betwixt

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I would look into Behavioral Health Case Management or UR with an insurance company or hospital. Try Cigna, United Health Care, Anthem (WellPoint), etc.

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Specializes in ED, ICU, MS/MT, PCU, CM, House Sup, Frontline mgr.
CDeCapua said:
I have been a psych nurse for approx 30 yrs, the last 5 in forensics. d/t a recent back injury, I cannot continue in psych nursing at the AA degree level which involves direct pt care, including takedowns etc.... Bewildered and Betwixt

It will depend on where you live or the companies in the area. Many require a BSN and/or years of case management work experience. I doubt becoming a case manager is the quickest way to become employed as a nurse unless you know a hiring manager who will be willing to train you despite your credentials. In fact, that is my best suggestion.

Talk to your former employers and ask the hiring managers of the case management departments. If there was no CM department, then look at becoming an admitting nurse in Psych or for a SNF. With your past work experience, I cannot see why no one would be interested. Good luck.

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There is a CPUR credential, promulgated by a well-known company that shall remain nameless but is famous for inventing credentials and then making tons of money off of the people who want them. You pay for the course and books and exam, and take the course in the morning, take the exam in the afternoon, and pay to take all the required CE to recertify. We are talking big bucks here.

I walked in to the afternoon session having paid for the exam only and aced it on the basis of having worked field case management in work comp for six years and picking up a few of the handouts that somebody dropped on the floor at lunch break. I thought the whole thing was totally bogus and never even put it on my resume. It was, I guess, an expensive afternoon's entertainment, but I did want to see if this "certification" (which it isn't, it's a certificate) was really indicative of any special knowledge or capability. It wasn't, in my opinion.

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If anyone know what the online service that are used by insurance companies and facilities to give guidelines base on age, service, and co- mobidities could you post it . I want to increase my knowledge in this area of nursing.

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Specializes in Vents, Telemetry, Home Care, Home infusion.
Ptrcthllh said:
If anyone know what the online service that are used by insurance companies and facilities to give guidelines base on age, service, and co- mobidities could you post it . I want to increase my knowledge in this area of nursing.

Interqual criteria or Miliman criteria are the two programs used in Case Management/UR.

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Mersekrn, I see you are in OH do you work directly for Aetna or are you an AHH employee, under Aetna?

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Mersekrn, I thought I posted this but not sure where it went :-). I see you are in OH, do you work directly for Aetna or AHH ??

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Hi there,

Is it anyway we can communicate because I would like help obtaining a job as some kind of review nurse. Please email me at allenkiat@msn. I would really appreciate your help.

Thanks

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Hi , I was wondering if you still do UR as a nurse . I'm at the bedside for 10 years now and I'm lookin for a position like that to work from home . Have you heard of care manager RN ? Thanks

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There are several types of nursing jobs that allow you to work from home such as HEDIS, utilization review, clinical documentation improvement, RN coder, case management, auditing, etc.

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I have been trying to get into utilization review for over a year now. I'm only targeting certain employers so I know I'm limiting my odds but is there anything that anyone can offer as far as advice to either alter my resume somehow or gain a specific type of training or experience to help me to break into this area of nursing?. I have four years of acute, hospital experience and just over a year as a home health case manager, BSN-RN licensed. Any advice or input would be very much appreciated. Thank you

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