Utilization Review?

  1. I'm really interested in getting into utilization review. I currently have an opportunity that has presented itself but I need to give them an example of my work and honestly. . I'm not sure where to start and I want to really impress them. If I had a good example, I think I would take right off. . but the internet is just pathetic when it comes to examples. I started researching to see if there was a certification exam for utilization review nurses but all I can find is case management certification. (I figured a great review book for an exam would be a good reference.)

    So. . .

    Anyone here do utilization reviews? How did you get started? What can you recommend as a reference?

    Any advice you can provide, I would be extremely grateful for. . .my husband is currently out of work and I'm already working FT nights but this job (which is telecommuting) would be an IDEAL way for me to make some extra $$ to make ends meet and still be able to be home and see my kids (otherwise I'm going to have to pick up an additional PT job to make ends meet. Please, any UR nurses. . any advice you can provide. . I would be grateful for!!! TY!!!
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    About GoingCoastalRNCCRN

    Joined: Sep '11; Posts: 13; Likes: 3


  3. by   carolii
    I work for a company that does UR for the state Medicaid program, we review the medical record using screening criteria for medical necessity and write a brief summary of hospitalization which includes patient presentation to the ED, past med history, and evaluation and treatment that they recieved and their response to the treatment including stability upon discharge. Our summaries are forwarded to physician reviewers who either approve or deny. My advice: write objectively, spellcheck everything, and minimize use of abbreviations.
  4. by   coordinated
    Carolii, Did you have previous experience in utilization reviewing prior to this job? Does the position require travel? I am interested in anything else that comes to mind about your work in UR. Thank you.
  5. by   carolii
    Yes, not a lot, but about 1 1/2 yr doing on site field reviewer work/chart audits. But it was that -( the experience doing the chart audits) that my company hired me on.
    I was lucky though, the company had just won this big contract from another vendor
    and were scrambling to put together a staff to start doing the reviews to meet the deadlines. So they were less selective in the hiring process, than say a company that is well established already, like most of your third party insurance companies.

    It also helped that I had 13 years of acute hospital care nsg experience to draw knowledge from in terms of clinical judgements, etc.

    To answer your question the previous job,as an on site reviewer did require travel(you go to the medical records) and you function fairly independently. However at my present job,we work in an office and the medical records come to us via computer which is less stressful I think than trying to arrive punctually at sites and having to deal with the traffic , etc.
    We like to joke and call ourselves CCNs- certified cubicle nurses.
  6. by   3rdcareerRN
    " CCNs- certified cubicle nurses" -- that's great!

    I agree that doing the onsite chart reviews (such as for HEDIS QI/QA) is a good intro to seeing medical records and the patient encounter in a broader way.
  7. by   kellenl
    If you do not have UR experience you need to start transitioning into an administrative nursing position.
    In the hospitals I have worked at and now I am in insurance, we required a minimum of 3-5 years nursing experience with at least 1 year of QA/PA experience before you could do Case Mangement or UR. It's a great, flexible field to be in and you will love it!