Utilization Review Nurse: Making It Clear

jeastridge, BSN, RN

In today's world, we hear a lot about utilization review, prior approvals, allowable days, meeting criteria and many other phrases that are bandied about but which provoke little clarity. Although we understand the importance of rising health care costs, we also sometimes struggle to put together the roles that insurance companies, providers and medical facilities play in this complex dance of working to provide the best care possible. Utilization review nurses are one part of the puzzle: they are constantly at work advocating for patients and for their employers to make ongoing health care possible.

Recently, while having supper with my friend, Ann, I asked her about her work as a Utilization Review Nurse.

What kind of training and experience did you have before you got work as a UR nurse?

I had a RN, BSN and many years of experience working in a variety of nursing settings, including ICU, ER, Dialysis, Medical/Surgical, Floor Management, Dialysis, Case Management and private duty Pediatric Vent Nursing.
The extensive experience helped me get hired to work UR but I started there because I was pregnant and needed a job that was just a little less physical to help me through my difficult pregnancy.
UR nurses need to have a thorough understanding of nursing skills and medical conditions to help them understand and make important critical thinking decisions.

What did you like about being in UR?

I liked that I could use all that knowledge I had worked so hard to gather and apply it in a new way.
I also liked it when I could be an advocate for the patient-both in getting more information and in providing them with supportive information.
I felt like it was important work in that I was there to make sure the patient got what they needed and that the hospital was clear on length of stay, tests and other aspects of the care.
It is full time. Some companies do hire through temp agencies to see if the nurse is a good fit for their company.
I like to learn and have an inquiring mind. In UR, it helps to be curious and want to find out more.
This work rewards self-starters and people who have strong follow-through skills.

Were there downsides to UR work?

Looking at data all day long can be blinding.
Often we work in the insurance company's office. Sometimes UR nurses work from home.
There are times when we advocate for patients and the medical director doesn't see it our way and denies the claim-that can be hard.
For UR nurses that work in the hospital, it can be difficult for other nurses to understand what they are doing. At times, UR nurses may face some degree of suspicion or maybe just a sense of being outside the "group."

Ann went on to say, "Utilization Review Nurses can work for insurance companies or for hospitals. At insurance companies, they are part of the team that reviews the charts looking at diagnoses, criteria for a number of days and contributing information. At hospitals, they often work with the Case Management Team to make sure that the hospital gets reimbursed for the care they provide. At hospitals, they might talk with a variety of team members including other nurses to corroborate the need for the inpatient days."

The American Nurses Association states, "UR nurses are employed in inpatient and outpatient clinical settings, the insurance industry, and managed care companies. They serve as liaisons among the patient, provider, and third-party payer to help prevent overuse or misuse of medical resources in an effort to maximize provider reimbursement and minimize consumer payments." (Is utilization review the career for you? - American Nurse Today)

In our conversation, Ann emphasized that UR nursing is a great field, but it is not for every nurse. Besides a lot of experience in nursing and a BSN, UR nurses need to be able to stay focused over long periods of time on complicated material that may not be self-evident. In other words, the nurse has to be willing to keep investigating, "digging" if you will, to uncover the necessary facts.

As well as being detail-oriented, the effective UR nurse will know how to be a strong decision maker but balance that with being a team player. He/she will often work with the entire medical team and will need to be able to clearly communicate findings and next steps. It is also important that the potential UR nurse have a good phone presence.

It is not necessary to have any special certification in order to start work as a UR nurse. Hospitals, facilities and insurance companies generally provide orientation and training to do the job. Additional certification is available later for those who wish to further their careers including Certified Case Manager Training and certification through the American Board of Quality Assurance and Utilization Review Physicians.

After talking with Ann, I felt like I had a much clearer picture of what UR Nursing is all about. Bottom line: regardless of their employer, UR nurses work hard to help patients get the care they need.

Utilization Review Nurse: Making It Clear

What kind of training and experience did you have before you got work as a UR nurse?

What did you like about being in UR?

Were there downsides to UR work?

About jeastridge, BSN, RN

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