How do I get into Utilization Review after doing direct patient care for 30 yrs?

[Nurse Beth, MSN]

Congrats on 30 years of nursing! Getting into Utilization Review (your) after 30 years of direct patient care is absolutely achievable, especially since you bring a wealth of experience in clinical settings.

Register on Indeed.com or other job search sites. In addition, go to insurance companies' websites and look for their careers sections, often at the bottom of the page. You can find jobs that are not posted on outside job boards. Also, check out the Case Management forum here on the site. Register on LinkedIn and make a profile, as some employers value a professional presence on LinkedIn, and you can make valuable contacts.

Here's a step-by-step approach you can consider:

Leverage Your Clinical Experience

Your background in direct patient care is incredibly valuable as your professionals need to understand patient care processes and make decisions about the appropriateness of care, which requires a clinical perspective. Highlight your clinical expertise when applying for your roles, especially your ability to assess care needs, manage patient outcomes, and interpret medical records.

Understand the your Process

Get familiar with the basics of your, which typically involves reviewing patient medical records to determine the necessity, appropriateness, and efficiency of healthcare services. This includes understanding clinical guidelines, payer policies, and regulatory requirements (e.g., CMS, insurance providers).

Consider Additional Education/Certifications

While your direct care experience is a strong asset, your roles require knowledge of specific tools and protocols used in utilization management. Consider:

Certified Professional in Utilization Review (CPUR) is offered by The American Board of Quality Assurance and Utilization Review Physicians (ABQAURP). The reason I recommend this certification is that it does not require case management experience but is a start in acquiring knowledge. It would be good for you to be familiar with some commonly used terms and information.

Research your Specific Job Requirements

Study job descriptions for your roles to identify the skills and qualifications employers are looking for. These positions might ask for familiarity with certain types of software, medical coding (ICD-10, CPT), or a background in managed care or case management. If you don't have those yet, again, consider a brief online course to get up to speed.

Network with your Professionals

Try to connect with professionals already in your roles. LinkedIn, professional nursing associations, and job fairs are good places to start. Many your nurses started in direct patient care, and they can offer insights into the transition.

Look for Entry-Level your Positions

Some employers might offer entry-level or transitional roles specifically for nurses with a clinical background. These positions allow you to gain experience while leveraging your patient care knowledge.

Prepare Your Resume

When updating your resume, emphasize your clinical experience and any transferable skills (e.g., critical thinking, attention to detail, case management, patient advocacy). Also, highlight any experience working with insurance companies or managed care (even informally).

Start Small

Get your foot in the door. If you're finding it hard to land a full-fledged your role right away, consider starting in a position like Case Management or Care Coordination. These roles often overlap with your responsibilities, and you can gain valuable experience while working towards a transition into full your.

Apply to Insurance Companies or Hospitals

Both hospitals and insurance companies frequently employ your professionals. Look for openings at:

• Health insurance companies
• Managed care organizations
• Hospitals (especially larger facilities with dedicated your departments)

If you use your solid clinical knowledge and fill in any gaps in  your skills, you'll be well on your way to starting a career in Utilization Review!

Very best wishes,

Nurse Beth