Utilization Review Careers

Utilization review analysts and coordinators are usually registered nurses with clinical experience. They determine the appropriate patient admission, treatment and length of stay in hospitals and other health care facilities, and ensure that these factors comply with government and insurance policy reimbursement regulations. Utilization review opportunities appeal to nurses who want to leave the clinical setting and have a more regular work schedule.

Identification

Utilization review careers are available at insurance companies, hospitals and other health care facilities, and government agencies. Utilization reviewers create pre-certifications for admission in non-emergency cases, and determine how long an appropriate length of stay is for surgeries, childbirth and other procedures. They review and manage cases while the patients are in the hospital, then assist with discharge planning and post-discharge services such as follow-up appointments and home care.

Features

Utilization review nurses evaluate client needs and identify solutions to non-standard, more complex requests and health care issues, such as surgeries for patients with diabetes, auto-immune disorders and other conditions. They make inquiries of clients and provide explanations and information. They communicate with hospital staff, receiving calls to authorize services and calling for further clarification if necessary. They enter data into the computer while taking information over the phone.

Considerations

Nurses interested in a utilization review career must be able to work independently and with minimal supervision. They must have excellent judgment and are expected to only seek advice from nurse managers and physicians on the most complex problems, although many times they work in small teams and can confer with other utilization review nurses. They must be able to clearly understand insurance policy language to interpret coverage correctly. They are expected to identify cost-saving measures without compromising health care.

Significance

Registered nurses with Bachelor of Science degrees and clinical experience are preferred for utilization review careers because of the extensive knowledge necessary to analyze and evaluate cases. Utilization review analysts must understand medical terminology, medical and surgical techniques, various medical conditions and symptoms, practices and standards of health care, treatment alternatives and medications. They must be familiar with health care needs of special populations such as geriatric and disabled people. They also must understand legal codes and government regulations associated with the utilization process.

Potential

A career in utilization review is an excellent option for a nurse who would like a change from the clinical environment and have a work schedule which typically involves a standard Monday through Friday 40-hour week. These nurses usually work during the day, in comfortable climate-controlled offices, and they have little in-person contact with patients. Salaries commonly are somewhat lower than for registered nurses working in a clinical setting. Average salary for a utilization review nurse as of 2008 was about $55,000 to $67,000 a year depending on the workplace and experience, and pay generally increases with the size of the organization. Utilization review nurses also can advance to coordinator, which pays more as well.