Utilization review nurse info?

psychnurse127 · Sep 25, 2017

I know your post is over a year old but I figured my post could maybe help someone searching for the same question. I was in a similar situation and felt burnt out by floor nursing. I wanted a change and applied to any position available. Lo and behold I landed a job as a UR nurse for an insurance company. The company allowed nurses to work remotely from home so after a month of orientation, I was sent home to work. Every day is usually very similar. I have a case load that is sent to me by intake and I review each case by looking through all the medicals that were sent in which includes MD progress notes, PT notes, OT notes, nurse's notes, xrays, labs, etc. Basically everything and anything that the adjuster/attorney sends to us. I once had a case where the adjuster sent in 400+ pages of medicals. After reviewing the case, I determine if the claimant's request (surgery, therapy, DME, medication, etc) is medically necessary according to guidelines. If I feel that there is not enough evidence for me to approve the request, I send the request to a physician that also works for my company. That physician then either approves or denies the request. The approval or denial from the nurse or physician must have an explanation of why and what guidelines are used to determine the necessity. Once it is approved by the physician or by me, I compose a letter and send this letter out to the all parties including the claimant, requesting physician, adjuster, and attorney. I do this until all my cases are completed for the day. In between I make phone calls to doctor's offices, attorney's offices, etc if I feel that I need more information to make my determination. Hope this helps!