In the complex world of modern healthcare and the companies which manage patients' services, a utilization review nurse plays an important role. Hospitals and insurance providers employ these nurses to help determine if treatments which are underway or sought for authorization fall within the coverage parameters of a patient's insurance. Utilization review is one of the main ways health care providers and insurance companies control costs for the patients they serve.
Utilization review nurses who work for hospitals help ensure that individual patients are receiving care which matches their respective needs, and also make recommendations to clinical review boards regarding necessary adjustments.
For those who work for insurance providers, the job focuses more on the authorization and prior-authorization processes. Many policies are fairly explicit about the procedures they cover, which require review before being implemented. These review nurses examine each procedure and the history and medical needs of each patient while remaining fully aware of what is covered under his/her individual policy clauses. They then make recommendations which are held in high regard by the provider's authorization review board; these recommendations generally focus on whether certain operations, medications, or treatments are covered under the insured's policy. Sometimes, utilization review nurses may determine that either the patient or hospital is being served poorly by treatments currently in progress or being sought for authorization, and will make necessary recommendations to the clinical review board.
Many candidates for this position have already become registered nurses, and many health care providers and insurance companies prefer to hire nurses with both extensive hands-on nursing experience and administrative backgrounds. Utilization review nurses generally work during traditional business hours, and their time is divided between offices and clinical environments.
Utilization Review Nurse Tasks
Audit and analyze patient records to ensure quality patient care and appropriateness of services.
Interview or correspond with physicians to correct errors or omissions and to investigate questionable claims.
Analyze information gathered by investigation, and report findings and recommendations.
Modify patient treatment plans as indicated by patients' responses or case history.