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What is a Utilization Review Nurse?

A utilization review nurse is a certified registered nurse who works in the insurance industry to review the medical services provided to patients. Utilization review nurses ensure that the medical services are medically necessary for the patient and ensure that the patient is receiving the highest quality care.

Utilization review nurses work closely with the patient, patient’s family, insurance companies and healthcare providers to ensure that appropriate utilization of care is provided to the patient while also ensuring that the insurance company and healthcare provider follow the appropriate utilization guidelines and policies.

Utilization review nurses come from a variety of backgrounds such as hospitals, insurance companies, managed care organizations, and nursing homes. They typically hold a bachelor’s degree in nursing, and often a master’s degree in Health Systems Management or a related field.

What Responsibilities Does a Utilization Review Nurse Have?

Utilization review nurses have a variety of responsibilities. These include:

  • Reviewing the medical records provided by the patient and their healthcare provider and making sure the services provided and medications prescribed are the appropriate level of care
  • Assessing the medical appropriateness and necessity of services
  • Making recommendations to the patient and healthcare provider on alternate treatments, medications, and services
  • Working with insurance companies to ensure services and treatments are covered
  • Analyzing data related to the patient’s insurance coverage
  • Developing utilization guidelines and standards
  • Monitoring outpatient services for quality assurance
  • Assessing for discharge planning and services during the pre-admission process
  • Participating in utilization review or quality assurance committees
  • Negotiating claims and reimbursements between the patient, medical provider, and insurance carrier

What Skills Does a Utilization Review Nurse Need?

Utilization review nurses need a variety of skills in order to effectively do their job. These skills include:

  • Strong attention to detail in order to thoroughly review each medical service and to make sure the services are appropriate and medically necessary
  • Strong communication skills in order to coordinate with healthcare providers and insurance companies
  • Critical thinking skills in order to evaluate the data provided and make informed decisions
  • Knowledge of medical terminology so that they can accurately assess the healthcare services provided
  • Knowledge of the healthcare system and insurance companies so they can ensure the patient is receiving the best care at the best cost
  • Analytical skills in order to analyze data and make informed decisions
  • Computer skills in order to be able to access medical records and data

What is the Average Salary of a Utilization Review Nurse?

The average salary for a utilization review nurse varies based on experience and location. According to the Bureau of Labor Statistics, the median annual wage for utilization review nurses as of 2019 is $72,622.

What is the Job Outlook for a Utilization Review Nurse?

The job outlook for utilization review nurses is positive. According to the Bureau of Labor Statistics, the job outlook for utilization review nurses is expected to grow 9 percent from 2019 to 2029, which is faster than the average for all occupations.

Conclusion

Utilization review nurses help ensure that patients are receiving appropriate care and services as well as make sure that insurance companies are following guidelines. Utilization review nurses need a variety of skills such as attention to detail, critical thinking, and strong knowledge of the healthcare system in order to be successful. The average salary for a utilization review nurse is $72,622 per year and job outlook is expected to grow 9 percent from 2019 to 2029.

FAQs About Utilization Review Nurse

Q: Is a utilization review nurse a doctor?

A: No, a utilization review nurse is not a physician, they are a registered nurse.

Q: What qualifications do I need to be a utilization review nurse?

A: To be a utilization review nurse, you typically need to have at least a bachelor’s degree in nursing, and often need a master’s degree in a healthcare related field as well.

Q: What is the job outlook for utilization review nurses?

A: The job outlook for utilization review nurses is expected to grow 9 percent from 2019 to 2029, which is faster than the average for all occupations.

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