A nurse reviewer is a professional who examines medical records and treatment plans to see if they are covered by insurance. A slightly different nursing career as a nursing reviewer in a hospital who works on quality control issues is also referred to by this term. Both professions necessitate nursing education and experience to familiarize practitioners with the hospital environment and standards of care. They may require travel and may include perks such as health insurance and retirement accounts.
A nurse reviewer who works for an insurance company examines patient records to assess the treatments given to the patient. The treatments will be approved for payment if they appear to meet the insurance company’s standards. Records of treatments that have not been approved or endorsed by the insurance company will be rejected for payment on the grounds that they are outside the scope of insurance coverage.
Nurse reviewers visit doctors’ offices and hospitals, as well as home health care facilities, to assess the treatments given to patients receiving care at home. Their job requires them to stay current on medical standards of care as well as be familiar with the insurance company’s policies. A doctor can also collaborate with a nurse reviewer to develop a treatment plan that the insurance company will approve. Patients can challenge denials if they believe a treatment is the only option.
In a hospital, clinic, or other treatment facility, quality control with a nurse reviewer entails retaining a nurse or a team of nurses to review patient records. They search for indicators of poor quality, such as unusually high rates of complications, risky behavior, and so on. This data is used to develop policy and practice recommendations aimed at maintaining a high standard of care. Hospitals that use nurses for quality control have better patient outcomes and are more likely to win awards and other accolades.
For this type of nurse reviewer work, the nurse often works in a fixed setting, sometimes out of an office, reviewing patient records and compiling data. Nurses can learn quality control skills through training programs, and they can compile and process data using software programs. People in these jobs should have prior patient-care experience, as they will have gained skills and experiences from working directly with patients.