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Become An Utilization Review Nurse

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Working As An Utilization Review Nurse

  • Assisting and Caring for Others
  • Documenting/Recording Information
  • Getting Information
  • Making Decisions and Solving Problems
  • Updating and Using Relevant Knowledge
  • Deal with People

  • Unpleasant/Angry People

  • Unpleasant/Hazardous Environment

  • Make Decisions

  • $67,490

    Average Salary

What Does An Utilization Review Nurse Do

Registered nurses (RNs) provide and coordinate patient care, educate patients and the public about various health conditions, and provide advice and emotional support to patients and their family members.

Duties

Registered nurses typically do the following:

  • Record patients’ medical histories and symptoms
  • Administer patients’ medicines and treatments
  • Set up plans for patients’ care or contribute to existing plans
  • Observe patients and record the observations
  • Consult and collaborate with doctors and other healthcare professionals
  • Operate and monitor medical equipment
  • Help perform diagnostic tests and analyze the results
  • Teach patients and their families how to manage illnesses or injuries
  • Explain what to do at home after treatment

Most registered nurses work as part of a team with physicians and other healthcare specialists. Some registered nurses oversee licensed practical nurses, nursing assistants, and home health aides.

Registered nurses’ duties and titles often depend on where they work and the patients they work with. For example, an oncology nurse may work with cancer patients or a geriatric nurse may work with elderly patients. Some registered nurses combine one or more areas of practice. For example, a pediatric oncology nurse works with children and teens who have cancer.

Many possibilities for working with specific patient groups exist. The following list includes just a few examples:

Addiction nurses care for patients who need help to overcome addictions to alcohol, drugs, and other substances.

Cardiovascular nurses care for patients with heart disease and people who have had heart surgery.

Critical care nurses work in intensive-care units in hospitals, providing care to patients with serious, complex, and acute illnesses and injuries that need very close monitoring and treatment.

Genetics nurses provide screening, counseling, and treatment for patients with genetic disorders, such as cystic fibrosis.

Neonatology nurses take care of newborn babies.

Nephrology nurses care for patients who have kidney-related health issues stemming from diabetes, high blood pressure, substance abuse, or other causes.

Rehabilitation nurses care for patients with temporary or permanent disabilities.

Registered nurses may work to promote public health, by educating people on warning signs and symptoms of disease or managing chronic health conditions. They may also run health screenings, immunization clinics, blood drives, or other community outreach programs. Other nurses staff the health clinics in schools.

Some nurses do not work directly with patients, but they must still have an active registered nurse license. For example, they may work as nurse educators, healthcare consultants, public policy advisors, researchers, hospital administrators, salespeople for pharmaceutical and medical supply companies, or as medical writers and editors.

Clinical nurse specialists (CNSs) are a type of advanced practice registered nurse (APRN). They provide direct patient care in one of many nursing specialties, such as psychiatric-mental health or pediatrics. CNSs also provide indirect care, by working with other nurses and various other staff to improve the quality of care that patients receive. They often serve in leadership roles and may educate and advise other nursing staff. CNSs also may conduct research and may advocate for certain policies.

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How To Become An Utilization Review Nurse

Registered nurses usually take one of three education paths: a Bachelor of Science degree in nursing (BSN), an associate’s degree in nursing (ADN), or a diploma from an approved nursing program. Registered nurses also must be licensed.

Education

In all nursing education programs, students take courses in anatomy, physiology, microbiology, chemistry, nutrition, psychology, and other social and behavioral sciences, as well as in liberal arts. BSN programs typically take 4 years to complete; ADN and diploma programs usually take 2 to 3 years to complete. All programs include supervised clinical experience.

Bachelor’s degree programs usually include additional education in the physical and social sciences, communication, leadership, and critical thinking. These programs also offer more clinical experience in nonhospital settings. A bachelor’s degree or higher is often necessary for administrative positions, research, consulting, and teaching.

Generally, licensed graduates of any of the three types of education programs (bachelor’s, associate’s, or diploma) qualify for entry-level positions as a staff nurse. However, employers—particularly those in hospitals—may require a bachelor’s degree.

Many registered nurses with an ADN or diploma choose to go back to school to earn a bachelor’s degree through an RN-to-BSN program. There are also master’s degree programs in nursing, combined bachelor’s and master’s programs, and accelerated programs for those who wish to enter the nursing profession and already hold a bachelor’s degree in another field. Some employers offer tuition reimbursement.

Clinical nurse specialists (CNSs) must earn a master’s degree in nursing and typically already have 1 or more years of work experience as an RN or in a related field. CNSs who conduct research typically need a doctoral degree.

Licenses, Certifications, and Registrations

In all states, the District of Columbia, and U.S. territories, registered nurses must have a nursing license. To become licensed, nurses must graduate from an approved nursing program and pass the National Council Licensure Examination (NCLEX-RN).

Other requirements for licensing vary by state. Each state’s board of nursing can give details. For more information on the NCLEX-RN and a list of state boards of nursing, visit the National Council of State Boards of Nursing.

Nurses may become certified through professional associations in specific areas, such as ambulatory care, gerontology, and pediatrics, among others. Although certification is usually voluntary, it demonstrates adherence to a higher standard, and some employers require it.

CNSs must satisfy additional state licensing requirements, such as earning specialty certifications. Contact state boards of nursing for specific requirements.

Important Qualities

Critical-thinking skills. Registered nurses must be able to assess changes in the health status of patients, including determining when to take corrective action and when to make referrals.

Communication skills. Registered nurses must be able to communicate effectively with patients in order to understand their concerns and assess their health conditions. Nurses need to explain instructions, such as how to take medication, clearly. They must be able to work in teams with other health professionals and communicate the patients’ needs.

Compassion. Registered nurses should be caring and empathetic when caring for patients.

Detail oriented. Registered nurses must be responsible and detail oriented because they must make sure that patients get the correct treatments and medicines at the right time.

Emotional stability. Registered nurses need emotional resilience and the ability to manage their emotions to cope with human suffering, emergencies, and other stresses.

Organizational skills. Nurses often work with multiple patients with various health needs. Organizational skills are critical to ensure that each patient is given appropriate care.

Physical stamina. Nurses should be comfortable performing physical tasks, such as moving patients. They may be on their feet for most of their shift.

Advancement

Most registered nurses begin as staff nurses in hospitals or community health settings. With experience, good performance, and continuous education, they can move to other settings or be promoted to positions with more responsibility.

In management, nurses can advance from assistant clinical nurse manager, charge nurse, or head nurse to more senior-level administrative roles, such as assistant director or director of nursing, vice president of nursing, or chief nursing officer. Increasingly, management-level nursing positions are requiring a graduate degree in nursing or health services administration. Administrative positions require leadership, communication skills, negotiation skills, and good judgment.

Some nurses move into the business side of healthcare. Their nursing expertise and experience on a healthcare team equip them to manage ambulatory, acute, home-based, and chronic care businesses. Employers—including hospitals, insurance companies, pharmaceutical manufacturers, and managed care organizations, among others—need registered nurses for jobs in health planning and development, marketing, consulting, policy development, and quality assurance.

Some RNs choose to become nurse anesthetists, nurse midwives, or nurse practitioners, which, along with clinical nurse specialists, are types of advanced practice registered nurses (APRNs). APRNs may provide primary and specialty care, and in many states they may prescribe medications.

Other nurses work as postsecondary teachers in colleges and universities.

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Utilization Review Nurse jobs

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Utilization Review Nurse Career Paths

Utilization Review Nurse
Medical Case Manager Career Coordinator Clinical Director
Administrative Director, Behavioral Health Services
11 Yearsyrs
Registered Nurse Supervisor Unit Manager Office Manager
Business Office Manager
8 Yearsyrs
Registered Nurse Case Manager Nursing Director Case Manager
Career Manager
6 Yearsyrs
Career Coordinator Clinical Director Medical Director
Chief Medical Officer
9 Yearsyrs
Career Coordinator Therapist Clinical Social Worker
Clinical Care Manager
8 Yearsyrs
Registered Nurse Case Manager Clinical Manager
Clinical Director
9 Yearsyrs
Nurse Case Manager Registered Nurse Case Manager Nursing Director
Clinical Services Director
11 Yearsyrs
Nurse Case Manager Case Manager
Director Of Case Management
11 Yearsyrs
Clinical Specialist Clinical Analyst Clinical Informatics Specialist
Director Of Informatics
12 Yearsyrs
Career Manager Project Manager Quality Manager
Director Of Quality Management
13 Yearsyrs
Staff Nurse Case Manager Social Worker
Director Of Social Services
6 Yearsyrs
School Nurse Registered Nurse Supervisor Career Manager
Health Care Manager
8 Yearsyrs
Medical Case Manager Career Manager
Managed Care Director
8 Yearsyrs
Nurse Liaison Clinical Liaison Medical Science Liaison
Medical Manager
6 Yearsyrs
Registered Nurse Supervisor Nurse Manager
Nurse Case Manager
9 Yearsyrs
Nurse Manager Registered Nurse Case Manager Patient Care Manager
Patient Relations Director
10 Yearsyrs
School Nurse Staff Nurse Nurse Manager
Patient Services Manager
8 Yearsyrs
Nurse Manager Nursing Director Quality Improvement Coordinator
Quality Improvement Manager
10 Yearsyrs
Staff Nurse Registered Nurse Supervisor
Registered Nurse Case Manager
8 Yearsyrs
Career Manager Senior Technician Specialist Licensed Practical Nurse
Resident Services Director
6 Yearsyrs
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Utilization Review Nurse Demographics

Gender

Female

89.4%

Male

9.2%

Unknown

1.5%
Ethnicity

White

83.2%

Hispanic or Latino

9.0%

Asian

5.7%

Unknown

1.4%

Black or African American

0.7%
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Languages Spoken

Spanish

58.3%

Russian

8.3%

French

6.3%

Chinese

4.2%

German

4.2%

Mandarin

4.2%

Carrier

4.2%

Portuguese

2.1%

Bulgarian

2.1%

Vietnamese

2.1%

Dakota

2.1%

Cantonese

2.1%
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Utilization Review Nurse Education

Schools

University of Phoenix

22.7%

Walden University

9.0%

Chamberlain College of Nursing

6.5%

Excelsior College

5.9%

Indiana Wesleyan University

5.6%

Tennessee State University

4.7%

Grand Canyon University

4.7%

Kaplan University

4.0%

Ohio University -

3.7%

University of Texas at Arlington

3.7%

University of Maryland - Baltimore

3.4%

Saint Joseph's College, New York

3.1%

Florida State College at Jacksonville

3.1%

Howard University

3.1%

Western Governors University

3.1%

Arizona State University

2.8%

Villanova University

2.8%

Liberty University

2.8%

University of Saint Francis

2.5%

New York University

2.5%
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Majors

Nursing

72.6%

Business

4.6%

Health Care Administration

4.6%

Management

2.4%

Nursing Science

2.2%

Psychology

1.6%

Health/Medical Preparatory Programs

1.5%

Social Work

1.2%

Public Health

1.1%

Education

1.0%

Nursing Assistants

0.9%

Mental Health Counseling

0.8%

School Counseling

0.8%

Family Practice Nursing

0.8%

Health Sciences And Services

0.7%

Liberal Arts

0.6%

Medical Assisting Services

0.6%

Computer Information Systems

0.6%

Counseling Psychology

0.6%

Accounting

0.5%
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Degrees

Bachelors

34.4%

Associate

21.9%

Masters

21.9%

Other

11.9%

Certificate

3.9%

Diploma

2.9%

License

1.7%

Doctorate

1.5%
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Top Skills for An Utilization Review Nurse

UtilizationReviewMedicalNecessityInterqualCriteriaMedicare/MedicaidDischargePlanningUtilizationManagementMillimanCareGuidelinesReviewNurseConcurrentReviewFacilityInsuranceCompaniesClinicalInformationHealthCareProvidersDurableMedicalEquipmentClinicalReviewCMSHedisPatientCareRetrospectiveReviewsMedicalRecordReview

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Top Utilization Review Nurse Skills

  1. Utilization Review
  2. Medical Necessity
  3. Interqual Criteria
You can check out examples of real life uses of top skills on resumes here:
  • Perform utilization review on requested medical treatment.
  • Appeal denials of payments based on medical necessity.
  • Assessed using InterQual criteria to monitor the medical necessity for hospital admissions.
  • Reviewed Medicare/Medicaid eligibility of hospitalizations to determine whether diagnosis and treatment are medically necessary for inpatient Concurrent, and Discharge dates.
  • Discharge planning and concurrent/retrospective medical records review for insurance coverage of hospitalization.

Top Utilization Review Nurse Employers

Utilization Review Nurse Videos

Attorney Erika L. Vargas explains Utilization Review (UR)

Utilization Review

How To Work From Home As A Nurse?

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