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What Is a Utilization Review Nurse?

A utilization review nurse ensures that a patient is getting the appropriate care on an individual basis.
A utilization nurse might be employed by an insurance company to determined whether medical claims should be paid.
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  • Written By: Mary McMahon
  • Edited By: O. Wallace
  • Last Modified Date: 12 September 2014
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A utilization review nurse is a registered nurse who reviews individual medical cases to confirm that they are getting the most appropriate care. These nursing professionals can work for insurance companies, determining whether or not care should be approved in specific situations, and they can also work in hospitals. The goal of members of this profession is to balance the needs of a patient with the need to reinforce policies, keep costs reasonable, and ensure that patients are provided with medical treatment which is suited to their situations.

Working as a utilization review nurse can be stressful, as it may involve situations and settings in which nurses are forced to make decisions which they may not personally agree with. For example, a nurse may feel that on compassionate grounds, a patient should have access to a particular treatment, but that the patient is not eligible for the treatment, based on the specifics of the patient's case and the policy of the hospital or insurance company. Members of this profession do need to possess compassion, but they also need to be able to review situations dispassionately to make decisions which are fair, even if they may be uncomfortable.

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At a hospital, a utilization review nurse examines patient cases if the hospital feels that a patient may not be receiving the appropriate treatment. For example, a doctor might recommend hospitalization, but the utilization reviewer might feel that the patient does not need to be hospitalized, and it would be better to discharge the patient to free up a bed, save the hospital money, and save money for the patient as well. Utilization review nurses also review situations like requests for medical imaging studies, the use of certain medications and treatments, and recommended medical procedures. Hospital nurses may also be concerned about whether or not patient cases meet the standards for reimbursement by insurance companies.

In an insurance company, the utilization review nurse inspects claims to determine whether or not they should be paid. The nurse weighs the patient's situation against the policy held by the patient, the standards of the insurance company, and the costs which may be involved in treatment. For example, requests for medications which prolong life are probably going to be denied if the patient is in hospice care, as hospice care is designed for end of life treatment. Likewise, if a utilization review nurse feels that a medication, procedure, or treatment is not medically indicated, it may be denied.

To work in this field, it is usually necessary to hold a current nursing license, and to have experience in the field. Many utilization review nurses have been nursing for 20 years or more, and they are familiar with nursing administration, hospital procedures, and the process of insurance reimbursement. Job openings are listed in many nursing trade magazines in addition to public forums. Nurses who are interested in specialized work such as utilization review for prisoners or members of the military may need to pass background checks and fulfill other requirements before they can start work.

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anon270062
Post 9

@catapult: If that is the reasoning you're using then you must also feel that a DON, CNO, or any manager is also not a nurse. Primary bedside nursing is the basis for all nursing. However, the policies, procedures, and best patient outcomes are provided by the managers, administrative, and ancillary (UR) nurses who study and interpret the data.

anon256103
Post 8

My question then, is: what knowledge do I need to get to UR opportunities? Coding? Insurance policies? Information Tech? I've been in nursing for 30 years. --Victoria

anon219474
Post 7

"Not a nursing job?" Funny, it takes all the knowledge I gained in years on the floor to have the depth pf knowledge to do this job. Not a nursing job? You sound like one of my patient's families not knowing what they were looking at while I did the care. They had no clue, but they had an opinion.

LadyBug1
Post 6

The job of a UR is not just the concern of money related to the client or the hospital. It is an unbiased view -- no more, no less. For the client, hospital, state, private sector whoever you work for! That is what makes the job difficult. And you must have years of experience under your belt to do it for those of you who "think" it isn't nursing. That is, you experience talking. You *can't* do it if you haven't been a 'real nurse'! It is the highest degree of nursing, in my opinion! And it saves the consumer, businesses and the state a wealth of money, agree or not! We are and will be needed for years to come.

anon160471
Post 5

I have been a RN for 15 years, working various areas from med/surg, telemetry, float nurse, GI lab, PACU, nursing home, etc. I have been in utilization review now for 18 months at a large hospital and it is very rewarding. Do I miss bedside care? No, but could I do this job without it? No. The experience I have gained over the years in various areas, has been so valuable to me. Utilization review is stressful, but very rewarding and I enjoy my job!

anon159226
Post 4

@anon148475 - I totally agree with you! I worked on the floor at a Women's Hospital for years. I am now a Utilization Review Nurse for an insurance company and it takes every bit of knowledge I gained from Nursing School to do this job, which is something I love because I was an OB RN for so long. You become too complacent with a specialty at the hospital/MD office.

There are so many Nursing opportunities out there, why not try out being a Utilization Review RN. It can't hurt! Plus it looks super awesome on your resume! You use your nursing knowledge for sure. My salary is totally awesome and I work at home!

anon148475
Post 3

For those of you who posted that the role of the utilization review nurse isn't an actual nursing job must not have any experience in this speciality. As a nurse who is almost done with her master's degree I find this very insulting. I worked the floor for years as a oncology and ob nurse.

The experience I gained working with physicians and other professionals as well as taking care of patients, has proved to be invaluable. I think you need to do a little more research or trade me roles for a week!

Denha
Post 2

While I would like to be optimistic about people who have utilization review nurse jobs, my experience in general with people who review others' medical needs has been negative. For example, the concern of money, in my opinion, should not be put before patients' needs unless the patient has actually expressed that himself or herself. However, I do wonder if this role will change in either its structure or its importance with the advent of national health care in the United States.

Catapult
Post 1

In some ways, the role of a utilization review nurse does not even strike me as an actual nursing job; while it is important that these people have experience with the medical profession, it honestly seems more like an office or lab coat job than the role of a nurse, someone who is constantly taking care of patients right out on the ward and in the operating room.

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