What is a Utilization Review Nurse?

A utilization review nurse is a registered nurse who examines individual medical cases to ensure that the best possible care is being provided. These nursing professionals can work for insurance companies or in hospitals, determining whether or not care should be approved in specific situations. Members of this profession strive to strike a balance between a patient’s needs and the need to enforce policies, keep costs low, and ensure that patients receive medical treatment that is appropriate for their circumstances.

Working as a utilization review nurse can be stressful because it often involves situations and settings in which nurses are forced to make decisions with which they disagree. For example, a nurse may believe that a patient should have access to a particular treatment on compassionate grounds, but the patient is not eligible for the treatment due to the specifics of the patient’s case and the hospital or insurance company’s policy. Members of this profession must have compassion, but they must also be able to look at situations objectively in order to make fair decisions, even if they are difficult.

A utilization review nurse examines patient cases in a hospital if the hospital believes a patient is not receiving appropriate treatment. For example, a doctor may recommend hospitalization, but the utilization reviewer may believe that the patient does not require hospitalization and that it is better to discharge the patient to free up a bed, save money for the hospital, and save money for the patient. Requests for medical imaging studies, the use of certain medications and treatments, and recommended medical procedures are all reviewed utilization review nurses. Hospital nurses may also be concerned about whether or not their patients’ cases meet the criteria for insurance reimbursement.

The utilization review nurse at an insurance company examines claims to determine whether they should be paid. The nurse considers the patient’s situation in light of the patient’s policy, the insurance company’s standards, and any potential treatment costs. Requests for life-prolonging medications, for example, are likely to be denied if the patient is in hospice care, which is designed for end-of-life care. A medication, procedure, or treatment may also be denied if a utilization review nurse believes it is not medically necessary.

A current nursing license and prior experience in the field are usually required to work in this field. Many utilization review nurses have worked as nurses for more than 20 years and are familiar with nursing administration, hospital procedures, and the insurance reimbursement process. Many nursing trade magazines, as well as public forums, publish job openings. Nurses interested in specialized work, such as utilization review for prisoners or military personnel, may be required to pass background checks and meet other requirements before starting work.