A utilization review nurse is a registered nurse who reviews individual medical cases to confirm that they are getting the most appropriate care. These nursing professionals can work for insurance companies, determining whether or not care should be approved in specific situations, and they can also work in hospitals. The goal of members of this profession is to balance the needs of a patient with the need to reinforce policies, keep costs reasonable, and ensure that patients are provided with medical treatment which is suited to their situations.
Working as a utilization review nurse can be stressful, as it may involve situations and settings in which nurses are forced to make decisions which they may not personally agree with. For example, a nurse may feel that on compassionate grounds, a patient should have access to a particular treatment, but that the patient is not eligible for the treatment, based on the specifics of the patient's case and the policy of the hospital or insurance company. Members of this profession do need to possess compassion, but they also need to be able to review situations dispassionately to make decisions which are fair, even if they may be uncomfortable.
At a hospital, a utilization review nurse examines patient cases if the hospital feels that a patient may not be receiving the appropriate treatment. For example, a doctor might recommend hospitalization, but the utilization reviewer might feel that the patient does not need to be hospitalized, and it would be better to discharge the patient to free up a bed, save the hospital money, and save money for the patient as well. Utilization review nurses also review situations like requests for medical imaging studies, the use of certain medications and treatments, and recommended medical procedures. Hospital nurses may also be concerned about whether or not patient cases meet the standards for reimbursement by insurance companies.
In an insurance company, the utilization review nurse inspects claims to determine whether or not they should be paid. The nurse weighs the patient's situation against the policy held by the patient, the standards of the insurance company, and the costs which may be involved in treatment. For example, requests for medications which prolong life are probably going to be denied if the patient is in hospice care, as hospice care is designed for end of life treatment. Likewise, if a utilization review nurse feels that a medication, procedure, or treatment is not medically indicated, it may be denied.
To work in this field, it is usually necessary to hold a current nursing license, and to have experience in the field. Many utilization review nurses have been nursing for 20 years or more, and they are familiar with nursing administration, hospital procedures, and the process of insurance reimbursement. Job openings are listed in many nursing trade magazines in addition to public forums. Nurses who are interested in specialized work such as utilization review for prisoners or members of the military may need to pass background checks and fulfill other requirements before they can start work.
