Summary: Utilization Review Nurses are Registered Nurses who review patient files or information and check if proper care is being rendered. They go through recorded documents to determine if improvement is necessary. They can work with insurance companies as a nurse consultant in determining if a specific care for the patient.
Duties: Utilization Review Nurses work is to evaluate the patient’s current condition. For example, a doctor is treating a patient; after treatment the Utilization Review Nurse will assess if the patient still needs to stay in the hospital or be sent home. They provide recommendation to the doctor about their evaluation with the patient. With Utilization Review Nurses that work in insurance companies, their job is to review medical claims and determine whether they are paid or not. They serve as consultants. They review patient’s present medical condition and the possible cure that they can get. Base on that, Utilization Review Nurse will determine whether to approve the medical needs of the patient or not. The Utilization Review Nurse evaluates the patient’s situation against the hospital policies, insurance company’s standards and the cost of involved treatments.
Education and Training Requirements: Utilization Review Nurse is a specialized work, a person at this position have already graduated from Bachelor of Science in Nursing and is currently a registered nurse. They should also have 20 years of work experience as a hospital nurse. They should be knowledge on administrative work, hospital procedures and insurance reimbursement.
Knowledge and Skills Requirements: Utilization Review Nurse is a very stressful job. They deal with patients and patient’s relatives, doctors, and people from insurance companies. A Utilization Review Nurse must have patience in dealing with a lot of people. They know correct hospital procedures, nursing administrative work and how insurance works. They analyze each situation carefully while thinking fast.
Working Conditions: Utilization Review Nurses are usually seen in hospital settings. They work in shifts and do rounds in hospital. They have an option to extend their working hours if the situation needs it and they can also be on-call sometimes. While if a Utilization Review Nurse work in insurance company. They work during business hour form 8 am to 5pm.
Salary: A Utilization Review Nurse may receive an average pay of $52,000. The amount of salary of a Utilization Review Nurse may vary because of benefits, company, experience, industry and location. Others, like a Registered Nurse may receive a pay amounting to $50,000 annually.