Utilization Review?

carolii · Sep 25, 2011

I work for a company that does UR for the state Medicaid program, we review the medical record using screening criteria for medical necessity and write a brief summary of hospitalization which includes patient presentation to the ED, past med history, and evaluation and treatment that they recieved and their response to the treatment including stability upon discharge. Our summaries are forwarded to physician reviewers who either approve or deny. My advice: write objectively, spellcheck everything, and minimize use of abbreviations.

coordinated · Feb 3, 2012

Carolii, Did you have previous experience in utilization reviewing prior to this job? Does the position require travel? I am interested in anything else that comes to mind about your work in UR. Thank you.

carolii · Feb 3, 2012

Yes, not a lot, but about 1 1/2 yr doing on site field reviewer work/chart audits. But it was that -( the experience doing the chart audits) that my company hired me on.

I was lucky though, the company had just won this big contract from another vendor

and were scrambling to put together a staff to start doing the reviews to meet the deadlines. So they were less selective in the hiring process, than say a company that is well established already, like most of your third party insurance companies.

It also helped that I had 13 years of acute hospital care nsg experience to draw knowledge from in terms of clinical judgements, etc.

To answer your question the previous job,as an on site reviewer did require travel(you go to the medical records) and you function fairly independently. However at my present job,we work in an office and the medical records come to us via computer which is less stressful I think than trying to arrive punctually at sites and having to deal with the traffic , etc.

We like to joke and call ourselves CCNs- certified cubicle nurses.

3rdcareerRN · Feb 16, 2012

" CCNs- certified cubicle nurses" -- that's great!

I agree that doing the onsite chart reviews (such as for HEDIS QI/QA) is a good intro to seeing medical records and the patient encounter in a broader way.

kellenl · Mar 28, 2012

If you do not have UR experience you need to start transitioning into an administrative nursing position.

In the hospitals I have worked at and now I am in insurance, we required a minimum of 3-5 years nursing experience with at least 1 year of QA/PA experience before you could do Case Mangement or UR. It's a great, flexible field to be in and you will love it!