Work From Home: Utilization Review

Melissa Mills, BSN

Another popular work from home option is to become a utilization review nurse.

Utilization review nurses work behind the scenes to control costs while monitoring the quality of patient care. With the growing cost of healthcare, this role has increased in popularity since the 1980's with the emergence of managed care.

Oftentimes, the roles of utilization review and case management are combined. The skill set needed to be a successful utilization review nurse is practically the same in most healthcare organizations. Healthcare organization may require 2 years of nursing experience and a Bachelor's Degree to be eligible for hire.

Where Do They Work?

Hospitals

Insurance Companies

Health care providers offices

Workers compensations bureaus

Military

Correctional facilities

Government agencies, such as Medicare and Medicaid

What Do They Do?

Utilization review nurses complete reviews of charts and make decisions about the necessity of care to be provided to patients. They advise on questions of hospital admissions, length of stay, imaging studies, surgeries, medications, referrals and many other treatments and procedures. The goal of the review is to ensure that patients are receiving necessary care that is evidenced based and cost-effective.

By evaluating care that physicians want to provide in a prospective review, utilization review nurses ensure it is an effective treatment based on the diagnosis being treated. In retrospective reviews, they audit the chart to ensure that the correct procedures were completed based on the events that occurred.

To complete these reviews, many companies use evidence based guidelines such as MCG Health, McKesson's InterQual Criteria or the Official Disability Guidelines. Some cases may not fit into these guidelines perfectly, so utilization review nurses need to have great critical thinking skills along with diverse experiences in patient care.

Below are the primary concepts used by utilization review nurses:

Cost-Effectiveness: The utilization review nurse will review charts to ensure that the proposed treatment and level of care is cost-effective. Making sure that the patient is in the correct level of care can save the patient and their insurance company a significant amount of money.

For in-patient care, this could mean reviewing for the right time to transfer a patient from the Intensive Care Unit to a step down unit. This could also mean choosing the correct type of rehabilitation facility for a patient based on their rehabilitation needs and goals.

Necessary and Reasonable Care: Have you ever had to have a test done, such as an MRI or colonoscopy? Did they scheduler say that your care or treatment needed to be "pre-approved" or "pre-authorized" before it was completed? If so, your medical care has been reviewed by a utilization review nurse.

They review the charts to ensure that the care requested is necessary and reasonable based on evidence based medicine guidelines.

For example, if a patient has a mild tear of the meniscus and the physician has requested surgery before completing any non-invasive treatments, such as Physical Therapy, the utilization review nurse will likely have this case come across their desk.

Their review would require them to review all of the patients complaints, all diagnostics and treatment completed and evidence based medicine guidelines for this diagnosis. The nurse would then approve or deny the physician's request for surgery based on their review of all of the information.

Clinical Judgement: Everything above almost sounds as though it could be fed into a computer and a decision could be automated, right? Well, just as with other areas of nursing, you must have a personal connection and clinical judgement.

The utilization review nurse is using all of the above tools as guidelines, not as a rule book. They make the final decision based on all of the information reviewed and their clinical judgement. This is where the experience of working in the hospital or other facility becomes necessary.

Informed Decisions: These nurses are well-versed in different types of health coverage. In order to make these decisions, they must know what is covered by the company or government agency paying for the care. They must have a good working knowledge of Medicare, Medicaid, Workers Compensation or private health coverage, depending on their place of employment..

Utilization review nurses are an important part of the healthcare team. If you are interested in learning more about the role of the utilization review nurse and possible certifications, review the following:

American Board of Quality Assurance and Utilization Review Physicians

Commissions for Case Manager Certification

URAC