Are you considering a career in nursing? Have you considered working as a Utilization Review (UR) Nurse? These healthcare professionals are critical in ensuring that patients receive appropriate care while keeping costs to a minimum.

The demand for UR Nurses is increasing, making it an excellent career option for those passionate about healthcare. In this article, we’ll look at how to become a UR Nurse, what their job entails, what salary you can expect, and much more!

Key Takeaways

• Utilization review nurses are essential in ensuring that patients receive high-quality care while keeping costs under control. 
• UR nurses, or utilization review nurses, can often be found in medical facilities and hospitals.
• Utilization review nursing is a promising field with a bright job outlook due to increased service demand.

Table of Contents

• What is a Utilization Review Nurse?
• What Does a Utilization Review Nurse Do?
• Where Do Utilization Review Nurses Work?
• How to Become a Utilization Review Nurse
• Utilization Review Nurse Salary
• Continuing Education Obligations for Utilization Review Nurses
• Career Outlook for a Utilization Review Nurse
• FAQs About Utilization Review Nurse

What is a Utilization Review Nurse?

Utilization review nurses are registered nurses who play an essential role in the healthcare system by evaluating patient care and collaborating with insurance companies, doctors, and other healthcare professionals. They gather data, assess patients’ medical conditions, and devise the best care plan for each patient. They also decide on the length of a patient’s hospital stay and create after-care plans to ensure a smooth transition out of the hospital. 

What Does a Utilization Review Nurse Do?

Utilization review nurses ensure patients receive high-quality care while controlling costs. They work with healthcare providers and patients to develop the best treatment plan and with insurance companies to provide coverage.

Duties and Responsibilities

• Records patient care information following hospital and doctor’s office visits to help patients and their organizations keep healthcare costs low.
• Collaborates primarily with nurses, doctors, and patients to provide the best possible care.
• Based on the patient’s condition and doctor’s orders, decides on a treatment plan for each patient under their care.
• Examines the patient’s insurance and develop a treatment plan based on it.
• Assesses the patient’s condition and treatment progress regularly and obtains the doctor’s approval for the plan.
• Communicates with the patient’s family to assist them in understanding the treatment plan and teaching them how to follow it if the patient is discharged.

Skills

If you’re considering becoming a UR nurse, remember you’ll be an essential part of the healthcare team. It would help if you were well-versed in health insurance, technology, and working independently in a fast-paced environment. To be an effective UR nurse, you must possess the following skills:

• A thorough understanding of the various types of health insurance coverage available, as well as the ability to advocate for patients and their families.
• The ability to establish firm boundaries with patients and their families to provide the best possible care.
• Knowledge of how to use technology, such as electronic health records (EHRs) and other computer-based systems.
• The ability to remain calm in stressful situations while focusing on patient care.
• The ability to navigate complicated paperwork, such as insurance claims and medical records.
• The ability to make sound decisions in a fast-paced environment to provide the best possible care to patients.

Where Do Utilization Review Nurses Work?

Utilization review nurses, or UR nurses, are commonly found in hospitals and medical facilities. Some may, however, work in private practices, remotely or for insurance companies. Depending on their work environment, UR nurses may have a variety of responsibilities. For example, those who work from home might be in charge of conducting chart reviews and writing reports, whereas those who work in a hospital may interact directly with patients and their families.

Regardless of the setting, all UR nurses are responsible for ensuring patients receive the best possible care at the lowest possible cost.

How to Become a Utilization Review Nurse

Enroll in a Nursing Program

The first step is to earn a nursing degree. Begin by earning an Associate’s Degree in Nursing or, preferably, a Bachelor of Science in Nursing (BSN). Many colleges and universities offer four-year pre-licensure Bachelor of Science in Nursing (BSN) programs. Some UR nurses have earned a master’s degree in nursing, which can provide them with additional knowledge and expertise.

Pass The NCLEX-RN

After completing your nursing degree, you must pass the NCLEX-RN licensure exam. All states require this exam to practice as a registered nurse (RN).

Gain Experience

To become a UR nurse, you must first gain two to three years of experience as an acute care nurse. This experience will assist you in developing the clinical skills and knowledge required to become an effective UR nurse.

Do Your Research

You can begin looking for UR nurse positions when you have enough experience as an acute care nurse. Look for job openings and learn what types of resumes, qualifications, and experience are required.

Meet The Requirements

You can begin applying for UR nurse jobs once you’ve met all the essentials! To become a certified UR nurse, you must first complete certification programs, which typically last three to four months. You’ll also need to fulfill any additional requirements for the UR nurse position you’re interested in.

Utilization Review Nurse Salary

According to the U.S. Bureau of Labor Statistics (BLS), the median annual salary for registered nurses in 2021 will be $77,600, or $37.31 per hour. Although the BLS does not specify a salary for utilization review nurses, Salary.com reports that they earn an average of $85,100, with a salary range of $75,600 to $93,900. In addition, UR nurses may receive an average of $9,000 in overtime pay per year.

Salary by Years of Experience

The annual salary of UR nurses is linked to their years of experience, with more experience typically resulting in higher pay. Based on their years of experience, the following are the average hourly wages for UR nurses:

• $27.24 for less than a year of experience
• $30.90 for 1-4 years of experience
• $34.06 for 5-9 years of experience
• $37.03 for 10-19 years of experience
• Experience of 20 years or more: $37.00

Highest Paying States for Utilization Review Nurses

• District of Columbia: $42.69 per hour or $128,968 per year
• New York: $42.66 per hour or $128,883 per year
• California: $39.99 per hour or $120,826 per year
• Massachusetts: $39.59 per hour or $119,608 per year
• Washington: $39.10 per hour or $118,147 per year

Highest Paying Cities for Utilization Review Nurses

• San Francisco, CA: $45.41 per hour or $137,202 per year
• Northridge, CA: $43.23 per hour or $130,610 per year
• San Jose, CA: $42.84 per hour or $129,437 per year         
• Washington, DC: $42.71 per hour or $129,033 per year
• New York, NY: $42.66 per hour or $128,883 per year

Continuing Education Obligations for Utilization Review Nurses

There is no specific certification needed to become a UR nurse. As a result, obtaining multiple certifications in patient care coordination, healthcare planning, and case management can improve your chances of finding work in this nursing field. Some qualifications for UR nursing include the following:

Nursing Case Management Certification (CMGT – BC)

The American Nurses Credentialing Center provides Nursing Case Management Certification (CMGT – BC) (ANCC). This certification is valid for five years and must be renewed by completing 75 continuing education contact hours (CH), selecting one of eight certification renewal categories, and paying the renewal fee.

Healthcare Risk Management Certificate (HRM)

The American Board of Quality Assurance and Utilization Review Physicians offers certification in Healthcare Quality and Management (HCQM) (ABQAURP). This certification must be renewed every two years and requires at least “8 CME/CE credit hours of continuing education as relevant to the fields of Healthcare Quality and management per 2-year recertification cycle” and keeping all account balances up to date.

Certification in Healthcare Quality and Management (HCQM) 

The American Society for Healthcare Risk Management offers a Healthcare Risk Management Certificate (HRM) (ASHRM). This credential requires completing a three-module course, each module earning 13 contact hours toward Continuing Nursing Education (CNE). This credential does not require recertification, according to the ASHRM website.

Career Outlook for a Utilization Review Nurse

Utilization review nursing is a promising field with a bright job outlook due to increased service demand. As the healthcare industry evolves, the role of UR nurses in improving patient outcomes while lowering costs becomes increasingly important. These nurses help healthcare organizations save money by ensuring patients receive the best possible care.

The job outlook for utilization review nurses is bright, with a projected 12% increase between 2018 and 2028. This increase is due to rising healthcare costs, which have prompted healthcare organizations to seek more cost-effective care options. Approximately 371,500 new jobs for UR nurses are expected to be created across the United States.

FAQs About Utilization Review Nurse

What is utilization review in healthcare?

The utilization review involves comparing a patient’s health and the care they receive to evidence-based care guidelines. This procedure assists UR nurses in determining the best treatment and care setting for the patient’s healthcare journey.

What is the difference between utilization review & utilization management?

Utilization review (UR) examines patient information and medical records to determine whether the treatment and services provided are appropriate and comprehensive while avoiding unnecessary medical care. Utilization management (UM) seeks to improve healthcare systems and provide proper levels of treatment by analyzing UR results, reducing the likelihood of cases requiring further evaluation due to ineffective or unnecessary treatment.

Are utilization review and case management the same?

Utilization review (UR) and case management (CM) are two related but distinct concepts that aim to provide the best possible care to patients while remaining cost-effective. Although they both share this goal, their scope and focus differ. The primary purpose of UR is to ensure the medical necessity of care and treatment services. UR nurses ensure that patients only receive clinically necessary and appropriate services for their condition.