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This question is about utilization review nurse resumes.
What is utilization in nursing?
Utilization in nursing consists of a review nurse who monitors patient care plans to ensure the proper level of care is provided. UR nurses consult both doctors as well as coverage providers regarding patient care plans.
There are utilization review nurses working for both care providers as well as insurance companies. These individuals work together, using protocols to gauge the correct level of care for each patient.
If working for a hospital, you would review a patient's case file using benchmark injuries or symptoms of illness to validate the level of care that they are receiving. A patient may be placed in the ICU unnecessarily.
It is your job to consult with the medical staff to determine why this placement has been made. If a patient is due to be discharged, but your review finds cause to extend their stay, you would contact the insurer, who would then provide for the extended stay.
Some UR nurses work for plan providers. Their role is to advocate for the insurer and make sure that the proper level of care is being provided, no more or less.
They may ask for clarification on tests or procedures ordered by the hospital that may be unnecessary. It is their medical suggestions that the private insurer will use to determine the level of care the plan will cover.
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