How to be a Utilization Review Nurse?

Specialties Case Management

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I have ten years experience as a Nurse. Mostly Operating Room. But I am very interested in becoming a Utilization Review Nurse. How can I become one? Do I need to take classes? What else can I do? Feedback or suggestions would be much appreciated!

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Specializes in Case mgmt., rehab, (CRRN), LTC & psych.

Apply to the major insurance companies (e.g. United Healthcare, Aetna, Anthem, Blue Cross/Blue Shield, Cigna, Humana, Kaiser Permanente, Assurant, Molina). Search the career sections of their websites for utilization management RN positions.

While some companies prefer case management experience, they will train the right candidate. No classes or special education is necessary to enter utilization review.

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Just curious.. Why do you want to be a UR nurse?

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Just apply. If you do prior authorization it helps to have home health experience but concurrent review hospital experience is preferred. Good luck, I love my job as PA nurse.

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Specializes in ER, Med Surg, Ob/Gyn, Clinical teaching.

Hey I was wondering, do these institution have part-time / PRN positions?

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I am a part of the American Association of Managed Care Nurses (aamcn.org), and they offer the CMCN (Certified Managed Care Nurse) prep course for certification which covers quality & utilization management and case management overview. It's a good introductory course to utilization/care management. It's a self-study course, that's now hosted online. They have a sale running on it until 5/19/2017 to promote the 2017 updates.

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Specializes in ED, ICU, MS/MT, PCU, CM, House Sup, Frontline mgr.
Hey I was wondering, do these institution have part-time / PRN positions?

I personally do not know about insurance companies, but I know that hospitals have PRN, Short Hour, and Part-time positions for UR.

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It really just depends on the setting that you apply to. Inpatient settings usually prefer experience/require years of UR experience. Insurance companies prefer the UR experience but do not require. I can only speak for insurance company UR. I worked for 3 years as a psych nurse and wanted to try something different and actually got a job as a UR nurse for a third party insurance company. They didn't require any special certification or classes. They were looking with someone with clinical experience and willingness to learn. After about a month of on-site training, I was sent home and was allowed to work from home.

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Specializes in Case Manager/Administrator.

I know you are asking for experience or how to get it but I wanted to give you the whole overview.

If you want hospital or even insurance Utilization review again like so many other have informed... just apply. I do know the Blues and Ameriben is hiring and you can work from home. I started with no experience in insurance and thought insurance companies were big and bad.

Your duties will be to review clinical documentation and compare to evidence based industry standards. An example would be if a patient has Crohns disease and the request is for Remicade. You would review what the patient has tried, what works , not work, weight-really get a summary of your patient history and current status. You then use policies/industry standards (this includes the Remicade FDA full prescribing sheet). If it meets the criteria/policy guidelines form Insurance then you approve, if not then you ask for additional information or send to the Medical Director for review. Please note you are expected to complete/review a set number of cases per day, I think the average is 20-30 cases. If you do not have the information then you request the information.

Some cases get complicated, some are quick approval and some well you just scratch your head and think wow this is my medical profession. As a whole I love UR/CM, I feel I can go back into direct patient cares as I volunteer at a red cross center so I keep my clinical skills up-to-date. I have work everything from Chemotherapy, transplants to Rheumatology to Gastroparesis...and all in-between.

A lot of misconception when going to work for an insurance company, I had them. Thought the insurance company kept monies they deny, practiced of denial until you just went away...told the providers what to do...these are myths. Insurance companies only manage what the company you work or spouses work for has decided for your health benefits. We approve way more than we deny so it is in the provider best interest to know the criteria for what they are asking for and submit supporting documentation based on that criteria, I tell them this all the time-transparency.

Insurance companies do not tell providers what they can and cannot prescribed or what procedures they may provide. An example is IV Iron Infusions and the place of service. Injectafer is the most expensive of the IV iron medication and a great deal of providers ask for this medication, they send in Labs and ask for this IV in an outpatient hospital. There are other IV Iron infusions that produce similar results and are more cost effective i.e. Fereheme or Venofer come to mind (the cost difference can be as high as 2000.00 per infusion). I want to know why Injectafer was picked instead of a more cost effective medication and why this needs to be completed in a hospital verses a infusion suite like say from Option Care/Walgreens (not corner of happy healthy but a true infusion suite that has experience RN staff on site, has crash carts and pharmacists). When the provider submits supporting documentation I am looking for issues such as patient had past IV infusion with SOB, bad stick frail veins-prior addict, passed out...rash all over body...I will gladly approve in outpatient hospital but if I do not get that kind of documentation then I send to a medical advisor who will then determine (usually a partial approval for IV iron) the provider still has to pick which IV iron (other than Injectafer) and denial for place of service in out patient hospital.

When I write the partial approval/denial it goes something like this: Allow IV Venofer infusions not greater than 200 mg and not more than 3 infusions to be administered in a non-hospital infusion suite as medical necessary per policy 123456, and Denial of place of service in a hospital outpatient setting per policy 12345. This verbiage is inserted into an insurance letter that goes out to the patient and provider.

This is just a small example of how my days go when it comes to reviewing for medical necessity.

Good luck to you and hopefully the start of a new career.

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Im a former peds nurse. I just kept applying until I got in. Honestly I was just looking for a job away from bedside. It's actually quite interesting. I work in an office for now bur eventually I will be working from home where the other 12-14 UM nurses work. We do reviews using interqual. I honestly had no idea what it was until I was called back for an interview and got online and researched. Sk far I like it. It's a major change going from 3 nights a week to 5 days a week. Like life altering. I'm still adjusting

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On 9/27/2017 at 3:59 PM, caramellhoney said:

Im a former peds nurse. I just kept applying until I got in. Honestly I was just looking for a job away from bedside. It's actually quite interesting. I work in an office for now bur eventually I will be working from home where the other 12-14 UM nurses work. We do reviews using interqual. I honestly had no idea what it was until I was called back for an interview and got online and researched. Sk far I like it. It's a major change going from 3 nights a week to 5 days a week. Like life altering. I'm still adjusting

How did you end up adjusting to 5 days a week? Did you end up liking this job? ?

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On 9/25/2017 at 8:11 AM, psychnurse127 said:

It really just depends on the setting that you apply to. Inpatient settings usually prefer experience/require years of your experience. Insurance companies prefer the your experience but do not require. I can only speak for insurance company your. I worked for 3 years as a psych nurse and wanted to try something different and actually got a job as a your nurse for a third party insurance company. They didn't require any special certification or classes. They were looking with someone with clinical experience and willingness to learn. After about a month of on-site training, I was sent home and was allowed to work from home.

Hi, do you enjoy your position? I'm trying to learn more about this position and it seems good but I've made the mistake of getting a job that was worse than what I has so I am terrified 

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