The job of a utilization reviewer (UR) is to set standards for the appropriateness and efficiency of patient health care and to ensure that those standards are followed. It is possible to conduct a review both during and after the provision of services. Pre-admission review or discharge planning are examples of utilization review jobs, which overlap with utilization management, a related discipline. Directors, managers, supervisors, and coordinators are the most common jobs that fall under the UR umbrella.
Some job titles for utilization review may be similar. Some employers may designate them as a UR nurse, a UR case manager, a UR analyst, a UR specialist, or simply UR staff. Employer-specific definitions of these terms may exist. Specific job definitions can usually be found in the related job description, or the prospective employer should be able to provide them.
Experience in nursing, social work, risk management, dental, psychiatric, or other specialty fields may qualify applicants for utilization review jobs. Three years of related experience is frequently required by employers. Other degrees or certificates may be accepted, but a bachelor’s or master’s degree, or an active nursing license – either registered nurse (RN) or licensed practical nurse (LPN) – may be required. It is usually preferred to have knowledge of diagnostic codes and medical insurance software.
Employees in utilization review jobs may work for companies that offer utilization review services to hospitals and other institutions. They may also be hired directly by hospitals or institutions who conduct their own audits. Sometimes the professional is self-employed, working for a hospital or institution as a private contractor.
A utilization review director is usually in charge of overseeing all aspects of a specific utilization review program. Typically, the UR manager or UR supervisor interviews, hires, supervises, and trains employees. This position is also responsible for ensuring that laws and regulations are followed. Supervisory or managerial experience, a bachelor’s degree in a relevant field, and a current nursing license are frequently required.
Typically, the utilization review coordinator reviews patient charts to ensure that treatment and length of stay are both appropriate and cost-effective. If the patient requires a longer stay or a different treatment, the coordinator usually contacts the patient’s insurance company to confirm continued coverage under the policy. If a conflict arises, the coordinator will usually refer it to the utilization review committee, which usually consists of hospital doctors.