Utilization review nurse advice

Specialties Case Management


Hey Everyone! I am looking into a career that is not bedside. I am looking into concurrent/utilization review nursing for insurance companies. Does anyone know anything about it or is working in the field? I am trying to understand the day to day process and exactly what you do when you review the charts etc. Also about this interqual.

Hi - I am new here and found your post. I have been an RN for over 20 years. I work as a UM Reviewer. It's definitely a specialty. Basically you learn the Health Plan criteria and systematically apply this knowledge to the medical records you are reviewing. Once your review is complete, you make a decision to approve, pend, deny, or send to the Medical Director(s) for further review.

It is mostly straight-forward but of course there will always be out of the norm cases. Good luck to you!

Specializes in Telemetry.

Hi babynurse1996 and nursep2015!  Nursep2015 I hope you were successful in landing a position. Could either of you please shed light on burnout in the UM position? Or is this mostly seen with Case Management position? Do you have trouble with burnout and could you share how many cases you are expected to complete in a certain time frame? I'm looking to change from my care management position to U.R./U.M. but I see so many people having issues with too high caseload or major stress related to case mgmt and I'm wondering if it will be the same for U.R./U.M.


13 Posts

I'm currently working concurrent review and as mentioned it is straightforward and I feel burnout really is more bored out of my mind. I know, I'm a remote worker and should be thankful, and I am, some days I just feel glazed over reading medical information on screen. 

Guess it depends on the person. I don't have burnout and like others, enjoy working remote. 

Specializes in Utilization Review Radiology Onc, Women's Health.

I just left my Prior Authorization job 1 week into training.  It wasn't what I thought it would be.....at least not at this particular company.  I thought I'd be spending my time reviewing the patient's clinical picture against NCD/LCD/MCG criteria for medical necessity but instead it was a lot of verifying coverage, verifying providers in or out of network. THEN if they were out of network then you're hunting down in network providers, calling them to see if they'd take a new patient, THEN calling the ordering provider to try and redirect the service.  Felt more like a patient navigator.  I'm hoping it's not like that everywhere because I enjoy doing the actual clinical reviews, not making phone calls all day.

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