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Utilization review nurse career guide (Duties, education & salary)
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What is utilization review nursing?
Utilization review nurses help advocate for the best healthcare services and providers for patients to fit their healthcare plans, and conversely, to help individuals find the right medical plans for their unique health concerns. Their goal is to eliminate the stress of worrying about paying for care when the patient is already anxious about a diagnosed medical condition, an upcoming procedure or hospitalization, while keeping the hospital’s budget and costs in mind.
Steps to become a UR nurse
Have an investigative nature.
If you like solving puzzles and digging into the details of the fine print to provide a positive outcome, this may be a great nursing field for you. Do you like working with large amounts of information and data and finding a solution to a problem and are you creative enough to find ways to make do with tight resources or find ways around what appears to be an immovable obstacle? As a UR nurse you’ll deal with administrative and insurance company legalities and regulations so you’ll need to be innovative within the contract law and persistent to get the job done for the benefits of your patient, the hospital and the insurance company.
Earn a Bachelor of Science in Nursing (BSN).
You may be able to become a UR nurse with an ADN, but you will likely need to earn a four-year bachelor’s degree, ideally a Bachelor of Science in Nursing. Your BSN should come from an accredited nursing program to maximize your employment opportunities.
Pass the NCLEX-RN to earn your RN license to practice.
Since you’ll need to be a practicing RN to specialize in UR nursing, you’ll need to study for and pass the NCLEX-RN. Once you pass the NCLEX you can apply for licensing and pass a background check and fingerprinting for your state. You may also need to take and pass a CPR course.
Get experience in case management—or just get experience.
While experience in case management may be an optional step, understanding the logistics and responsibilities that a nurse case manager deals with on a daily basis will help you do a better job and give you the organizational skills to supplement your knowledge of healthcare insurance and claim procedures. Regardless of whether you gain case management or acute care nursing experience, you will likely need a couple years of clinical experience before you join the utilization review management field.
Earn professional certification.
Getting experience in the related areas of utility nursing can only help you do your job better and may provide guidance as to specific sections of utility nursing that you may want to focus on in the future. Professional certification is the best way to do that and there are options for utilization review nurses in risk management, case management and healthcare quality management.
What do utilization review nurses do?
Utilization review nurses work as advisors in managed care facilities, hospitals and for insurance companies. They decide whether specific care for a patient is covered by their healthcare insurance or not. As healthcare costs continue to rise, utilization review nurses serve a unique purpose in that they review and manage medical resources. They assess a patient’s holistic healthcare needs with their medical insurance coverage to ensure that the care provided is cost effective, enforces policies—and that it covers the services necessary for the patient.
Utilization review nurses serve a unique purpose in that they review and manage medical resources for patients—and the healthcare facility.
Utilization review nurses rely upon a three-step assessment process:
Utilization review nurses need to weigh costs against the medical obligation of providing care to the patient. A utilization review nurse may need to approve or deny a specific treatment, a test or a medication for the patient because of their insurance limitations, and they may then be tasked with helping source a better policy or coverage if the need for medical care is ongoing.
Utilization nurses may also review requests pertaining to patient hospitalization, and whether a particular test is necessary, and they may recommend other medical procedures or assess whether the case meets the standards for reimbursement by the insurance company. They ensure that patient care stays at a particular level of quality and then reassess if a patient’s ongoing health issues change.
What it takes to be a utilization review nurse
Like any nursing specialization, certain traits and skills may benefit those choosing to enter the utilization review nursing field. Some skills that may be of benefit to practicing as a UR nurse include:
- Autonomy:
- Most utilization review nurses do their work independently, though they communicate with patients, teams of insurance company and other hospital employees.
- Documentation:
- UR nurses must document everything in a patient’s chart because it can affect the effectiveness of patient care and the financial integrity of the hospital. Accurate and complete documentation reduces errors and denied claims which in turn maximizes reimbursement from insurance companies and minimizes out of pocket costs for patients.
- Good interpersonal skills:
- Patient care will be a top priority and explaining why or why not to patients when it comes to critical procedures and tests around their healthcare will be part of the daily routine.
- Analysis and detail:
- Insurance policies of any type are detailed and complex, and UR nurses need to deep dive into the fine print to see what’s covered or not for a patient’s wellbeing and understand the risk involved.
- Keep up on state and federal regulatory requirements:
- Balancing what may be a regional or national healthcare policy with local patient care coordination takes knowledge and deftness. Being up to date and up to task on regulations and laws is a must.
- Time management:
- A patient could need an emergency procedure, so UR nurses may need to juggle a time-critical case with patients needing approval for preventative or specialized tests such as a colonoscopy. Prioritizing and working efficiently is a must.
- Collaboration:
- The job consists of working with hospital or healthcare facility staff, nurse case managers, insurance representatives and most of all, patients. UR nurses should be collaborators so they can come to the best conclusion for the patient without minimizing other stakeholders’ needs.
Where utilization review nurses work
UR nurses have the opportunity to work inside a healthcare facility or externally mainly due to their unique role as a liaison between patient, provider and insurance company:
Education options for UR nurses
While some UR nurses may be able to find work after earning an associate degree, most employers require a bachelor’s degree, preferably a BSN.
About the Bachelor of Science in Nursing (BSN)
- Prerequisites: Prerequisites include courses in natural sciences such as chemistry, microbiology, anatomy, physiology and nutrition; plus, math-based courses like statistics. Some schools may require set hours of volunteer healthcare facility work and a minimum GPA.
- Core curriculum: Coursework may include psychology, management and leadership, health promotion, pharmacology and pathophysiology. Other required coursework may focus on critical thinking skills and health care resources. Clinical simulation classes and labs may also be part of the core curriculum.
- Clinical experience: Hands-on supervised clinical training may occur in almost any healthcare setting, including hospitals, outpatient clinics, public health agencies or long-term care facilities.
- Time to complete: 4 years of full-time study
Online UR Nurse Programs
You can find programs that are at least partly online—with coursework online and labs and clinical hours in person. These programs require more self-direction, organization and discipline than programs that are entirely in person, but they may be perfect for those who have to work or need to fit their studies around family and children.
Accelerated ADN-to-BSN programs could also be a good option for nurses who already have an ADN but want to pursue a bachelor’s while continuing to work.
What to Look for in a School
There are more than 2,600 nursing programs in the United States, with around 1,000 offering accredited BSN programs. Choosing the right one is a personal choice, but there are some things you should look for regardless of the degree you’re pursuing:
- Accreditation:
- Accreditation will ensure that a program adheres to common standards of education and quality. In addition, you’ll have to attend an accredited program to apply for federal financial aid and most employers prefer graduation from an accredited program when hiring nurses.
- Graduate student services:
- What does your program provide in terms of job placement services, internships, resume building and career counseling? Will it help you translate your degree into a nursing job?
- Program success:
- Ask about the rate of students passing the NCLEX-RN licensure exam on their first try, what the graduation rate of the nursing program is and how many students from the most recent graduating class have found nursing jobs.
Licensure
After graduating from a BSN program, students must pass the NCLEX-RN exam to obtain a license to practice. The NCLEX-RN is a national exam and is required for practice in all 50 states and Canada. The exam is offered through the National Council of State Boards of Nursing and is designed to evaluate the competency of nursing school graduates.
The test is computerized, consisting of between 74 and 145 questions and each answer guides the computer program to choose subsequent questions. The NCSBN says the exam now includes “next generation features, using real-world case studies to measure a nurse’s ability to think more critically and make the right decisions”. The test has a five-hour time limit to complete.
Questions on the test, and the percentage of exam and weight of importance, are on these topics:
There are plenty of options for test preparation help. Your school may offer study aid resources, and you can find others online from test prep companies such as Kaplan Test Prep, Princeton Review and Board Vitals.
Once you pass the test, you’ll be ready for licensure by your state nursing board, which may also require you to pass background and drug tests and complete a CPR class.
Certification in Utilization Review Nursing
Certification can help nurses advance in their career journey. They provide the opportunity to specialize in a particular area of nursing and offer new skills to take your duties up a level. The most common specialty credentials for utilization review nurses include the following certifications (though there are others), which involve taking a course of study and then passing an exam:
| Certification award | Who offers the certification | What it does |
|---|---|---|
| Certified Professional in Health Care Risk Management Certification (CPHRM) | American Society for Health Care Risk Management | Provides knowledge in clinical and patient safety, risk financing, legal and regulatory, healthcare operations and claims and litigation |
| Nurse Case Management Certification (CMGT-BC) | American Nurses Credentialing Center | Provides entry-level clinical knowledge and skills for RNs in the nursing case management specialty after their initial licensure |
| Certification in Healthcare Quality and Management (HCQM) | American Board of Quality Assurance and Utilization Review Physicians | Provides knowledge and tools to help reduce medical errors, ensure patient safety, eliminate unnecessary services and avoid delays in patient care |
| Accredited Case Manager (ACM) | American Case Management Association | Tests core case management knowledge shared by nurse and social worker case managers, as well as competency in their individual skills |
Utilization review nurse salary
The U.S. Bureau of Labor Statistics (BLS) reports salaries for registered nurses in general but does not specifically cite salary data for utilization review nurses. According to the BLS, the median annual pay for registered nurses is $86,070.
Here are median annual salaries for registered nurses in your state:
The BLS says nursing jobs will grow by 5.6% through 2032, which is slightly faster than the national average for all jobs. The growth is largely due to the “growing number of older Americans needing healthcare,” says the BLS. “Because baby boomers are living longer, they’re requiring more healthcare, often for chronic conditions such as diabetes, Alzheimer’s and obesity,” they say.
Frequently asked questions (FAQs)
Is utilization review nursing a good job?
UR nursing is a great job for nurses who prefer indirect patient care and have an aptitude for detail, time management, organization, routine and independence. Though the job requires collaboration with stakeholders, such as insurance company administrators or hospital administrators, the majority of time on the job is spent poring through policies and regulatory details, spreadsheets, budgets and thinking about patient care and costs, which may in some cases, need to happen on a tight deadline.
Can you become a utilization review nurse with no experience?
Most facilities require around two years of experience in acute care nursing or nurse case management along with a BSN to practice as a UR nurse. American Nurse says UR nurses should have “several years’ experience in a particular specialty area and be familiar with current evidence-based practices, as well as the rules, regulations and expectations for each insurance company’s review criteria.”
Can you work as a utilization nurse from home?
Yes. Utilization nursing is an area of nursing that can be performed from home. In fact, some UR nurses may have the opportunity to work for insurance companies and healthcare facilities on a work-from-home basis. In this environment, utilization nurses may act more as a consultant and oversee a region or area of their community, providing insights and recommendations for care and cost-savings to more than one patient or care facility.
Utilization nurse vs case manager: What’s the difference?
Suzanne Jacobs, an RN with an MSN from Indiana University says on Quora that there are differences between the roles: “A utilization review nurse concurrently reviews a patient chart to make sure that insurance requirements are met for their inpatient stay. A case manager handles discharge planning, arranging for home health equipment, skilled nursing in a long-term care facility and home health needs.” But depending upon the hospital or facility and its size and budget, the roles may be integrated into one, or parts of each job may be combined or they may be kept entirely as two functions.
Published: June 15, 2023
Written and reported by:
All Nursing Schools Staff