What Are the Best Tips for a Utilization Review Nurse?

Nicole Etolen
Nicole Etolen

A utilization review nurse specializes in ensuring that patients get the highest level of care and treatment that they need while also taking into consideration the overall financial burden on the patient and his or her insurance policy. The best tips for a utilization review nurse include good problem solving, attention to detail, and experience in dealing with patients on a more hands-on level. Keeping informed about changes in medical procedures and new advances is also important.

Education requirements for becoming a utilization review nurse vary depending on the facility. Some require a Bachelors degree in nursing while others will accept a two-year degree. Working as a registered nurse for a certain amount of time, sometimes as long as 20 years, is often a requirement at many facilities. The main reason behind this requirement is that it gives the nurse a chance to gain a fuller understanding of treatments and procedures.

Attention to detail is a vital skill for a utilization review nurse, as part of the job involves examining patient intake records and ensuring that all the required documents are present. During the patient’s stay, the nurse continues to evaluate the records, and ensures that the services provided are covered by the patient’s insurance policy. The nurse is also in charge of formulating a discharge plan that meets the needs of the patient.

Good interpersonal skills will help a utilization review nurse perform a number of tasks more efficiently. A significant part of the job revolves around coordinating with doctors, specialists, and other parts of the patient’s medical team, as well as communicating with the insurance company and answering questions regarding authorization for certain services. Maintaining a proper business manner and understanding the best way to speak to each party involved ensures that the patient receives the best level of care possible.

A utilization review nurse must also stay informed about new techniques, medications, and other disease treatment options. Most nurses in any field are required to take a certain number of continuing education classes before renewing their license, but those in utilization review positions also need to keep up with changes in health insurance policies. When a new procedure is approved for use by patients, the nurse must also make it is covered by the insurance company.

One of the difficult aspects of the job of a utilization review nurse is balancing the patient’s desires with what the hospital or insurance company will allow. For example, if a patient requests a medically unnecessary alternative service because of personal preferences, the nurse has to determine if the patient’s needs outweigh the hospital’s policy and provide a “yes” or “no” answer regarding the request. Being able to balance compassion towards the patient with objectivity can help the nurse make difficult ethical decisions.

The best tip for a utilization review nurse to remember is that ultimately, the primary role of the job is to provide an advocate for the patient. Sometimes this means making tough decisions that go against the wishes of the patient, and sometimes it means going up against doctors or insurance policies to defend a decision. The nurse must always act in the patient’s best interests, regardless of how difficult or uncomfortable a position that may cause.

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