The purpose of utilization review (UR) jobs typically is to set standards for appropriateness and efficiency of patient health care and to ensure that those standards are adhered to. Review may take place both during and after the time services are provided. Utilization review jobs may also include pre-admission review or discharge planning, in which case it overlaps with a similar discipline called utilization management. Most jobs that fall under the UR umbrella include directors, managers, supervisors, and coordinators.
Some utilization review jobs may carry similar titles. For example, some employers might classify them as UR nurse, UR case manager, UR analyst, UR specialist, or simply UR staff. The definitions of these terms can vary by employer. Most times, specific definitions of the job can be found in the related job description, or the prospective employer should be able to provide clarification.
Applicants for utilization review jobs may qualify via experience in nursing, social work, risk management, dental, psychiatric, or other specialty fields. Employers frequently require three years of related experience. A bachelor’s or master’s degree, or an active nursing license – either registered nurse (RN) or licensed practical nurse (LPN) – may be required, although other degrees or certificates may be accepted. Knowledge of diagnostic codes and medical insurance software usually is preferred.
Employees working in utilization review jobs may work for companies that provide utilization review services to hospitals or institutions. They also might be employed directly by hospitals or institutions that perform their own reviews. Sometimes the professional is self-employed, working as a private contractor for a hospital or institution.
A utilization review director typically is the position responsible for directing all phases of the specific utilization review program. The UR manager or UR supervisor usually interviews, hires, oversees, and trains staff. This position also typically monitors compliance with statutes and regulations. Previous supervisory or managerial experience, a degree in an applicable field, and an active nursing license often are required.
The utilization review coordinator usually evaluates patient charts to ensure that treatment and length of stay are appropriate and cost-effective. If a longer stay or a different treatment is required, the coordinator typically contacts the patient’s insurance company to verify continued coverage under the patient’s policy. If a conflict arises, the coordinator usually will refer it to the utilization review committee, which typically includes doctors employed by the institution.