Utilization reviewers working in hospitals, managed care organizations and other healthcare settings are usually registered nurses (RN) who have strong clinical backgrounds and excellent communication skills, along with substantial experience with medical criteria and guidelines (such as InterQual and Milliman).  UR nurses are tasked with “the evaluation of the medical necessity, appropriateness, and efficiency of the use of healthcare services, procedures, and facilities under the provisions of the applicable health benefits plan.”  UR nurses are the ones who initially assess patients to determine if the length of hospitalization, the treatment involved, or the tests scheduled are appropriate for the patient’s condition.  On a daily basis, UR nurses talk with attending physicians, insurance companies, case managers, and others, as they guide and interpret the criteria for medical necessity at a particular service level, i.e. hospital, intensive outpatient treatment, acute rehabilitation inpatient services, etc.  For nurses interested in career opportunities,  utilization review careers offer a more regular work schedule, usually weekdays; more recently, both hospitals and managed care companies have initiated positions for week-end coverage and evening hours, as patients are admitted any time of the day, 24/7.

How does utilization review differ from case management?  In either case, nurses assess patient needs and find solutions to various health care-related issues.  While the focus of utilization review is on discharge planning, the focus of a case manager may include more complex problem solving and finding healthcare resources to meet the patient’s continuing needs in the community or other setting.  Utilization review nurses assess patients and if needed, refer cases for review to physicians.  Along the way, they also provide explanation of length of stay requirements; establish criteria necessary for the level of care, and other information.  Both utilization review nurses and case managers attend multi-disciplinary meetings, and coordinate patient care and treatment with the hospital staff.

Nurses experienced in utilization review who may be seeking a job change can view our  nurse job bulletin, which offers a variety of employment opportunities across the country.  If you are interested in utilization review as a career choice, some requirements include the ability to work with minimal supervision, work independently, ability to use sound judgement and be familiar with medical terminologies, medical conditions, and medications.   Knowledge of insurance policy language, alternate resources, and knowledge of criteria for decision-making is a must, in order to assist in finding cost-saving ways without compromising quality of patient health care resources.