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Nurses working in busy clinical arenas often hear about nurses who have left the floor to work in administrative departments. Such nurses may be encountered when they come requesting an update regarding a patient’s condition. However, most clinicians are far too preoccupied with their own responsibilities to learn what those nurses actually do or where they fit in their patient’s care continuum.

Utilization review is one of the least understood but incredibly essential departments in managing the cost of health care. Experienced nurses can bring a valuable perspective to this field.

How Does Utilization Review Fit into The Big Health Care Picture?

Utilization review nurses perform frequent case reviews, check medical records, speak with patients and care providers regarding treatment, and respond to the plan of care. They also make recommendations regarding the appropriateness of care for identified diagnoses based on the research results for those conditions. Furthermore, they also assist with determining whether a treatment meets the criteria for reimbursement by the insurance plan.

Utilization review nurses are also found in discharge planning roles to ensure that patients make a safe transition from acute to home care. They are involved in pre-certification, which determines whether a recommended procedure, medication, or therapy is appropriate for an individual according to the guidelines of their insurance plan.

How to Move into Utilization Review

The minimum credentials for working in utilization review are being licensed as a registered nurse and having a good base of general nursing experience in medical-surgical nursing. Many employers require a BSN over an associate’s degree, and sometimes specific certifications in utilization review or risk management.

Good communication skills, attention to detail, and the ability to excel under stress with minimal supervision are also critical for a successful utilization review career. Fortunately, on-the-job training is often provided for these roles.

The benefits of moving to utilization review can include a more regular schedule, a predictable salary, and perhaps even the ability to work remotely.

Elizabeth Binsfield, BA, RN
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