Utilization Review

  1. 0
    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 nusing for many years and need to get off the floor.. Thank you..

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  3. 19 Comments...

  4. 1
    You would need experience in dealing with insurance and/or chart reviews such as working in a clinic, physicians office, homecare or as a RNAC. That type of experience.
    tammygartley likes this.
  5. 5
    The company you work for will train you. You should have a basic knowledge of what a certain kind of patient needs for a certain inpatient stay. There are two online services that insurance companies and facilities use to give guidelines based on age, service, and co-morbidities. For example a 55 year old with a total hip replacement and no medical history other than arthritis, will need a much shorter stay than an 85 year old total hip secondary to fracture with dementia and COPD. Utilization reviewers make sure the patient gets only what they need, and at the lowest level of care where it can be provided. (The 55 year old will get PT home health, the 85 yr old will go to a SNF). You are making sure services are "utilized" appropriately.
  6. 3
    If you have years of floor experience you have some good experience to get started. Hospital utilization review is a bit different than insurance company utilization review. I am more familiar with hospital based review than insurance. Utilization usually does concurrent reviews of what is going on with the patient during the time they are in the hospital. Most hospitals use either Interqual criteria or Miliman criteria in which the nurse follows a set of criteria to determine if the patient's stay is medically necessary and if there is an intensity of service (receiving a level of care) that justifies hospitalization. You would probably be trained in that program after being hired. You will need to have a basic understanding of how both insurance and medicare works. Many hospitals are also using utilization review as documentation specialists where the reviewers also review the physicians documentation and what is going on with the patient and then querries the doctor to make sure that what the doctor is thinking and what he is treating is accurately and thoroughly doumented so that full reimbursement can be obtained. Medicare pays more for some diagnosis than others, but doctors do not always clearly document that and revenue is sometimes lost. there is certifications available but usually you have to work in a certain field for a year or two before taking the certification. Long answer but it is a good job for us older nurses whose knee can no longer take 12 hour days running all day long. I currently work in medical auditing and that also is an interesting area much like utilization review.
  7. 7
    I am not sure if I'm repeating anything that others wrote because I didn't read their posts completely. I am a Utilization Review Nurse Consultant for Aetna. I have been there for 3 years. The position does not require any previous UR experience, just the willingness and enthusiasm to learn. Aetna is worldwide and positions are available almost anywhere in the US and many parts of the world as well. What IS required is strong clinical skills and good technical skills. I run an average of 5 different programs simultaneously in order to do my Job. Aetna offers the ability to eventually work at home once you are successful in the role. This position is much like nursing, you are trained in all aspects of the position. We perform review of inpatient cases as well as some ambulatory cases that require review. Again, this is something that you can be trained to do.

    If Utilization review is something that interests you, I encourage you to work towards that goal. If it turns out to be something you don't care for, you always have your nursing to fall back on. Also, Aetna has some positions for precertification review nurses that are LPN's. So this is not just an RN role.

    I enjoy working for Aetna, I feel they are a strong leader in the insurance industry. The benefits are outstanding, the pay is extremely competitive. You feel like you are part of the big picture in many ways at Aetna. There are different avenues you can go with Aetna other than UR. You can do training and development, case management, quality assurance and beyond. There are so many opportunities, the list is endless.

    I wish you luck.
  8. 1
    Irecently applied for a utilization job at aetna. I am hoping that my years of experience as a staff RN in a hospital doesnt hurt me due to salary. I am willing to take a lower salary to get away from floor nursing. Anyone have any suggestions on how to deal with this?
    tammygartley likes this.
  9. 1
    Most utilzation jobs that I am aware of pays less, I guess because they can. There is always someone who will take the the job for the pay they offer. Nursing happens to be one of the few jobs/professions where you earn a decrease in pay the longer you are in the profession. They want and need your clinical expertise but because they can get away with it they pay less. With that said I do like what I do and after decades on the floor it is much easier on the body.
    tammygartley likes this.
  10. 4
    I know this thread is a bit old but I just wanted to say it is a FALSE idea that UR nurses make less than hospital nurses. Check salary.com and you will see they actually make a bit more. I am leaving a hospital position for a UR position (I have no UR experiene) and am getting a $5K annual increase.
    tammygartley, DizzyLizzyNurse, cyn_n, and 1 other like this.
  11. 3
    Quote from NurseRivera
    I know this thread is a bit old but I just wanted to say it is a FALSE idea that UR nurses make less than hospital nurses. Check salary.com and you will see they actually make a bit more. I am leaving a hospital position for a UR position (I have no UR experiene) and am getting a $5K annual increase.
    I make over 6k more annually for my um/cm job than i made in the hospital working nights, weekends and holidays. Ask me will I ever go back to the hospital full time!!
  12. 0
    I recently ran into an old colleague. She went into case management/medical review for an ER. I have been revising my resume to reflect my experience in management. I have 6 yrs floor ER experience and 1 yr in a clinic at a local jail.
    Since several people have mentioned being hired as case managers without experience, during the interview what suggestions do you have to sell yourself as an entry level case manager?
    Suggestions for websites that breakdown a lot of the verbage regarding CMS, CoPS, utilization review etc.


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