Are you a Registered Nurse looking for a new opportunity to utilize your clinical nursing skills? Are you interested in healthcare quality and cost issues? Utilization Review (UR), an aspect of managed healthcare, may be of interest to you.
Whether UR nurses work in hospitals, home health, outpatient settings or in insurance companies or other managed care organizations, the aim is the same – to help ensure quality and appropriateness of healthcare services for patients who are more and more becoming actively engaged consumers of healthcare.
Hospital or Managed Care Utilization Review?
A nurse working in hospital utilization review has responsibilities that include initial assessment of patients for severity of illness and appropriateness of stay. Patients who are admitted to varying levels of care should meet explicit criteria concerning their need to be admitted to a particular level of care, e.g. inpatient, rehabilitation, outpatient services. Generally the review of documentation includes obtaining information regarding the patient’s treatment plan, what tests are scheduled that need to be done on an inpatient basis (for in-hospital review) and understanding the beginnings of a discharge plan that can be considered. 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 working in managed care utilization review, the job is similar except it is not usually on-site at a healthcare setting. Most nurses working in a managed care environment, e.g. insurance company, health maintenance organization, or utilization review company, work with a hospital telephonically or visit a hospital or other healthcare setting to obtain information regarding the patient. Their primary connection is either the physician office or the utilization review nurse in the hospital or other setting.
What skills are needed for UR RN job?
Nurses who do Utilization Review have a general knowledge of the importance of quality, cost and care transition from one setting to another. Hospitals and managed care organizations look for nurses who have a strong clinical background, excellent communication skills, and up-to-date computer skills.
• Strong Clinical background: The more clinical experience you have, the better chance you will have to work in utilization review. Job requirements usually include several years work experience in a care setting or specialty. Why? Knowledge of individual patient needs, treatment plan, resources available either internal to the care setting or when discharged from a hospital for instance, is important in the day the day review of patients and the discharge planning role that nurses have.
• Excellent Communication skills: In the role of a UR Nurse, you communicate daily with physicians and other members of a multi-disciplinary team, or with the patient’s family in your review of an individual health status, treatment plan, and readiness for discharge to home or another facility for continuing care.
• Attention to detail in review of a medical record or patient history: Explicit medical review criteria or guidelines (e.g. InterQual and MCG Care Guidelines) is generally used to help determine whether an individual is receiving care at the appropriate level for the health condition being treated. The job includes an initial or ongoing review of a medical record or continuing patient assessment by telephone at periodic intervals of care. As you collect data and review information against explicit guidelines adopted by the hospital or managed care setting, it is important to be organized, prioritized and have the right information obtained in order that you or a UR supporting physician can determine the need for continuing care or other alternative care as needed.
Are you up for the job?
For nurses interested in career opportunities, utilization review careers can offer a more regular work schedule, usually weekdays, although both hospitals and managed care companies have initiated week-end coverage and evening hours’ responsibilities, as patients are admitted any time of the day, 24/7.
As you will see in the review of Internet job ads posted across the country, many openings are available for skilled UR Nurses. Like other areas of nursing, nurses with experience are preferred by employers when making hiring decisions. If you do not have experience, there may be hospitals or managed care companies willing to train on the job, especially as you have a desirable skill set relevant to a patient population or setting of care.
Resources to learn more about Utilization Review:
If you work at a hospital, talk with a colleague who does Utilization Review; ask them about their job and what they do every day. Keep your eye out for open positions at your hospital or health care setting where you are already employed.
To learn more about managed care and utilization review, the American Managed Care Nurses Association (AAMCN) offers a home study prep course (CEU approved) that can be helpful for nurses wanting to transition into the specialty of managed care that includes utilization review. Having such a course on your resume might inform a potential employer of your interest.
If your current job in nursing includes any responsibilities for discharge planning, care transition, participation and/or follow through in multi-disciplinary team planning, highlight these areas on your resume as you might apply to advertised positions as a Utilization Reviewer.
Career Growth in Utilization Review – The Future Looks Bright
Experience in UR as a specialty can lead to career opportunities and growth that include Case Management, Transitions in Care Coordination, Hospital DRG or Documentation Specialist, or Appeals Coordinator – all related jobs for which Utilization Review experience is helpful.
Nurses are important in the process of utilization review as hospitals and managed care organizations focus on providing quality and cost-effective care related to varied governmental or regulatory requirements or consumer expectations. Opportunities for Utilization Review nurses will continue to grow nationwide as the changing healthcare landscape continues to evolve. Nurses will continue to have an important role in helping to ensure quality and efficiency in the delivery of healthcare today and tomorrow.
Find jobs in utilization review, case management and quality at www.psninc.net/jobs
Terri Kapetanovic has more than 30 years of experience in healthcare quality, utilization review and case management. Terri has worked as a consultant for American Accreditation Healthcare Commission/URAC in Washington, DC, as one of the Commission’s first Utilization Review program accreditation reviewers.
Professional Services Network, Inc. (PSN) works with clients nationwide in the search and recruitment of experienced healthcare professionals in managed care and clinical roles for temporary assignments and direct hire opportunities. Additionally, PSN’s consultants work with organizations and providers seeking accreditation or re-accreditation with URAC or NCQA. For additional information regarding our services contact us at 301-460-4089 or email us at [email protected].
