Utilization Review: What It Is and How to Get Involved

If you’re a nurse looking for a career change, but still want to stay in healthcare, utilization review (UR) could be a great fit for you. This administrative line of work relies heavily on clinical knowledge and experience, and nurses make up the majority of utilization review employees. UR nurses review treatment plans, offer recommendations and help determine typical care guidelines for hospitals and insurance companies. Read on to discover what utilization review is and how to launch a career in it.

medical staff members having a discussion

What Is Utilization Review?

Utilization review involves conducting case reviews, checking medical records, speaking with patients and care providers and analyzing the care plan. UR nurses may make recommendations for care plans based on established guidelines for the diagnosed condition. They also help figure out whether or not the treatment is eligible for reimbursement from the insurance plan.

Utilization review is most closely associated with health insurance companies, but it may also be performed by hospitals, home health care services and other types of providers. (Hospitals must have an effective utilization review program in order to participate in Medicare and Medicaid.) Utilization is usually performed by nurses, though it may sometimes be done by a physician or another medical professional. Utilization review may sometimes be referred to as “utilization management” as well.

Utilization review may occur before, during or after patient care. Pre-care utilization review is known as prospective utilization and takes place when patients need prior authorization for a treatment or procedure (for example, the insurer needs to determine that a procedure is medically necessary before agreeing to cover it).

Concurrent utilization review occurs while a patient is receiving care. It’s used to ensure that patients are receiving high-quality care and to confirm that no changes need to be made to their treatment plans. In many cases, the UR nurse will give the proverbial thumbs-up on the patient’s care plan, but, in some situations, they may recommend improvements.

Retrospective utilization review occurs after a patient’s treatment has taken place. While this type of UR doesn’t affect patient care in the moment, it is helpful for insurers and hospitals seeking to establish treatment guidelines and protocols for a given condition.

UR nurses working for hospitals may sometimes also handle the discharge management for the patient in addition to the utilization review. When these two jobs are combined, the position is known as “charge management” instead.

How to Get Started in Utilization Review

If you’re looking to transition to utilization review, you’ll need to be licensed as a registered nurse and have a good base of experience in medical-surgical nursing, so don’t throw out those surgical scrubs quite yet. Many employers require that you at least have a BSN (as opposed to an associate’s degree), so you might need additional schooling as well. Some also look for specific certifications in areas such as utilization review or risk management. UR nurses also need to demonstrate many of the same skills that they used during their clinical nursing careers: attention to detail, great communication skills and the ability to work well under pressure.

Many types of nurses may transition into a career in utilization review for several reasons. For one, the more administrative work can be easier than clinical work, both physically and mentally, while still providing a challenge. UR nurses work more regular schedules, which means that their pay is predictable as well. Some UR nurses are even able to do part of their work remotely–an extra perk.

Example of Utilization Review

Let’s say that a patient, named Rob, is hospitalized overnight with a really severe case of the flu. The UR nurse visits him in the morning to review the medical record and take stock of the treatment Rob has received so far. Rob was admitted as inpatient care, a designation that means the patient requires more technical, skilled care. However, after reviewing his symptoms, the UR nurse decides that observation status is a more appropriate designation since Rob is too sick to be treated at his regular doctor’s office, but not sick enough to require full inpatient admission.

Other examples of utilization reviews might include determining whether or not a patient should be transferred to a specialty trauma ICU at a regional center or getting insurance approval for an extended hospital stay that goes beyond the typical guidelines.

Utilization review isn’t for every nurse, but if you’re ready to take on a more administrative role that draws on your clinical experience, becoming a UR nurse could be a great choice. If you can, reach out to UR nurses at your company to learn more about their work and whether or not it’s what you’re looking for.