Work From Home: Utilization Review

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    Utilization review nurses are important to the quality and cost-effectiveness of healthcare. It is similar to case management and many employers will allow you to work from home. Explore more about utilization review.

    Work From Home: Utilization Review

    Another popular work from home option is to become a utilization review nurse.

    Utilization review nurses work behind the scenes to control costs while monitoring the quality of patient care. With the growing cost of healthcare, this role has increased in popularity since the 1980's with the emergence of managed care.

    Oftentimes, the roles of utilization review and case management are combined. The skill set needed to be a successful utilization review nurse is practically the same in most healthcare organizations. Healthcare organization may require 2 years of nursing experience and a Bachelor's Degree to be eligible for hire.

    Where Do They Work?
    Hospitals
    Insurance Companies
    Health care providers offices
    Workers compensations bureaus
    Military
    Correctional facilities
    Government agencies, such as Medicare and Medicaid

    What Do They Do?

    Utilization review nurses complete reviews of charts and make decisions about the necessity of care to be provided to patients. They advise on questions of hospital admissions, length of stay, imaging studies, surgeries, medications, referrals and many other treatments and procedures. The goal of the review is to ensure that patients are receiving necessary care that is evidenced based and cost-effective.

    By evaluating care that physicians want to provide in a prospective review, utilization review nurses ensure it is an effective treatment based on the diagnosis being treated. In retrospective reviews, they audit the chart to ensure that the correct procedures were completed based on the events that occurred.

    To complete these reviews, many companies use evidence based guidelines such as MCG Health, McKesson's InterQual Criteria or the Official Disability Guidelines. Some cases may not fit into these guidelines perfectly, so utilization review nurses need to have great critical thinking skills along with diverse experiences in patient care.

    Below are the primary concepts used by utilization review nurses:


    Cost-Effectiveness: The utilization review nurse will review charts to ensure that the proposed treatment and level of care is cost-effective. Making sure that the patient is in the correct level of care can save the patient and their insurance company a significant amount of money.

    For in-patient care, this could mean reviewing for the right time to transfer a patient from the Intensive Care Unit to a step down unit. This could also mean choosing the correct type of rehabilitation facility for a patient based on their rehabilitation needs and goals.

    Necessary and Reasonable Care: Have you ever had to have a test done, such as an MRI or colonoscopy? Did they scheduler say that your care or treatment needed to be "pre-approved" or "pre-authorized" before it was completed? If so, your medical care has been reviewed by a utilization review nurse.

    They review the charts to ensure that the care requested is necessary and reasonable based on evidence based medicine guidelines.

    For example, if a patient has a mild tear of the meniscus and the physician has requested surgery before completing any non-invasive treatments, such as Physical Therapy, the utilization review nurse will likely have this case come across their desk.

    Their review would require them to review all of the patients complaints, all diagnostics and treatment completed and evidence based medicine guidelines for this diagnosis. The nurse would then approve or deny the physician's request for surgery based on their review of all of the information.

    Clinical Judgement: Everything above almost sounds as though it could be fed into a computer and a decision could be automated, right? Well, just as with other areas of nursing, you must have a personal connection and clinical judgement.

    The utilization review nurse is using all of the above tools as guidelines, not as a rule book. They make the final decision based on all of the information reviewed and their clinical judgement. This is where the experience of working in the hospital or other facility becomes necessary.

    Informed Decisions: These nurses are well-versed in different types of health coverage. In order to make these decisions, they must know what is covered by the company or government agency paying for the care. They must have a good working knowledge of Medicare, Medicaid, Workers Compensation or private health coverage, depending on their place of employment..

    Utilization review nurses are an important part of the healthcare team. If you are interested in learning more about the role of the utilization review nurse and possible certifications, review the following:

    American Board of Quality Assurance and Utilization Review Physicians

    Commissions for Case Manager Certification

    URAC
    Last edit by tnbutterfly on Dec 29, '17
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    Melissa Mills is a nurse who is on a journey of exploration and entrepreneurship. She is a healthcare writer who specializes in case management and leadership. When she is not in front of a computer, Melissa is busy with her husband, 3 kids, 2 dogs and a fat cat named Little Dude.

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    23 Comments

  3. by   Sparker RN
    How do you get the education for this position?
  4. by   NurseBecka2000
    Hello Sparker RN! I have been a case manager/UR nurse for about a year now. I have my BSN but no other education, most places require that and nursing experience, in my case I was a nurse for almost 17 yrs before I got this position. Different agencies may have more qualifications, but from what I've seen it's a combo of the BSN and experience.
  5. by   blondy2061h
    I would think this would be a difficult transition for many nurses as it would feel like putting money above patient care in some cases. Obviously the more expensive option is not the best in a lot of cases, though, such as the surgical repair for the torn meniscus example you provided.
  6. by   Brenda1959
    I worked doing psych UR for 5 years and I loved it. I would get calls from companies asking to help with medical issues. IT was wonderful.
  7. by   KatherineMCG
    Hi Melissa,

    Great article and thanks for linking to us (MCG)! Would you mind changing the link text to say just MCG Health? As we are no longer owned by the Milliman company.

    Thanks!
  8. by   melissa.mills1117
    Quote from Sparker RN
    How do you get the education for this position?
    Hi Sparker RN! As NurseBecka2000 stated, you do not need any special education to be a Utilization Review Nurse. Some companies may require a BSN, however some companies are fine with an associates degree in Nursing.

    The biggest things most companies look for is at least a year of clinical nursing experience. Does this sound like an area of nursing you would like to try?

    Melissa
  9. by   melissa.mills1117
    Quote from blondy2061h
    I would think this would be a difficult transition for many nurses as it would feel like putting money above patient care in some cases. Obviously the more expensive option is not the best in a lot of cases, though, such as the surgical repair for the torn meniscus example you provided.
    Blondy2061h,
    I have seen some nurses struggle in positions such as this or case management for the exact reason you stated above. However, these nurses are not picking and choosing what to approve or deny. They are using evidence based practice to make consistent decisions based on the information provided by the physician.

    Nurses who love bedside nursing, may not find a UR position to be a good fit for them.

    Melissa
  10. by   melissa.mills1117
    Quote from KatherineMCG
    Hi Melissa,

    Great article and thanks for linking to us (MCG)! Would you mind changing the link text to say just MCG Health? As we are no longer owned by the Milliman company.

    Thanks!
    Thanks KatherineMCG! I will see if this can be done!

    Melissa
  11. by   tnbutterfly
    Quote from KatherineMCG
    Hi Melissa,

    Great article and thanks for linking to us (MCG)! Would you mind changing the link text to say just MCG Health? As we are no longer owned by the Milliman company.

    Thanks!
    The edit has been made.
  12. by   qaqueen
    Thank you for this article. I have been seriously considering pursing an UR position, but was unsure of the scope of the position and requirements for employment.

    Thanks again.
  13. by   SharrisRN
    Hey there! I am in the early stages of UM. I work for an insurance company, my title is a utilization management review nurse, so i do mostly pre-cert now, but the option for work at home is a reality soon after starting if you work hard. I've been a RN for a little over 5 years now, and the only requirement was 2 or mor years of clinical nursing. I love it. Way different than anything I've ever done but way less stress
  14. by   melissa.mills1117
    Quote from SharrisRN
    Hey there! I am in the early stages of UM. I work for an insurance company, my title is a utilization management review nurse, so i do mostly pre-cert now, but the option for work at home is a reality soon after starting if you work hard. I've been a RN for a little over 5 years now, and the only requirement was 2 or mor years of clinical nursing. I love it. Way different than anything I've ever done but way less stress
    SharrisRN - So glad you are liking your career as a UM nurse! It is great when you finally find your niche! ~Melissa

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