Become a Utilization Review Nurse in 3 Steps

Nurse Types / Utilization Review Nurse

The U.S. spends more on healthcare than other developed countries yet has poorer outcomes. As a result, our government, insurance companies, and healthcare organizations are looking for ways to lower costs and improve care. That’s where utilization review nurses come in. 

Utilization review, or UR, is a growing specialty. Utilization review nurses are registered nurses (RNs) who monitor patient care and help control costs for various facilities and agencies. This post discusses the specialty and tells you how to become a utilization review nurse in three steps. 

• What is a utilization review nurse?
• What do utilization review nurses do?
• Where do utilization review nurses work?
• What are specific types of utilization review nurses? 
• How do you become a utilization review nurse in 3 steps?
• What are additional requirements of utilization review nurses? 
• What are the salary and career outlooks for utilization review nurses?

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What is a utilization review nurse?

Utilization review nurses, also called UR nurses, specialize in data collection and medical record review. They help bridge gaps between healthcare administration, direct care staff, and the insurance companies paying for services. 

UR nurses analyze cases. In addition, they identify trends that show areas for care quality improvement and cost savings within an organization. 

Qualities of a successful utilization review nurse

UR nursing is different from bedside nursing and requires unique skills. 

Much of the job requires sorting through records. Another important part of the job is coaching and training nurses, doctors, and other healthcare professionals in best practices. That’s why these specific qualities will help utilization review nurses succeed in their roles.

• Analytical and detail-oriented
• Strong leader
• Resourceful
• Adaptable
• Tech-savvy

What do utilization review nurses do?

UR nurses perform utilization reviews to identify care issues and validate patient treatment plans. They perform the following duties:

• Advise physicians on suggestions for documentation clarity and completeness
• Audit patient charts
• Collaborate with physicians when documentation does not appear to support the level of care
• Collect relevant medical information by phone or fax 
• Educate physicians and other care team members on appropriate resources, billing, and compliance issues
• Obtain or approve authorizations for treatments and services
• Provide staff coaching on utilization trends and ways to improve patient outcomes
• Review inpatient records for compliance with evidence-based guidelines

A day in the life of a utilization review nurse

Here’s an example of a typical day in the life of a utilization review nurse. 

• 8:00 a.m.  Log in to the work portal, check emails and voicemails. Address any urgent care updates or patient care issues.
• 9:00 a.m.  Attend a scheduled care conference on Zoom. 
• 10:00 a.m. Work on medical record reviews and phone providers to verify chart details, request medical records, or clarify incomplete notes. 
• 10:30 a.m.  Visit an assigned facility to check patient charts and talk with patients and families about their treatment plans.
• 1:30 p.m. Leave the facility to work from home for the remainder of the day. 
• 2:00 p.m.  Check emails and respond to messages from the team, providers, or patients. 
• 3:00 p.m.  Conduct reviews for patients that may need insurance approval for extended hospitalizations, special treatments, or transfer to a higher level of care.
• 5:30 p.m. Log off for the day!

Common conditions treated by utilization review nurses

Utilization management teams often monitor high-risk or high-utilizer patients (HUP) since they are associated with higher healthcare costs. One study said that the top 10% of HUPs accounted for 66% of U.S. healthcare expenditures. It also found that the top five most costly medical diagnoses were:

• Heart disease
• Trauma-related disorders
• Cancer
• Mental disorders
• COPD and asthma

UR nurses work with staff nurses and case managers to improve care and decrease costs for patients with these conditions. 

Where do utilization review nurses work?

UR nurses work for companies of all sizes. These nurses work at:

• Health systems
• Hospitals
• Physician office groups
• Insurance companies
• Government agencies
• Workers compensation bureaus
• U.S. military
• Correctional facilities
• Third-party agencies

Some UR nursing positions are remote, while others require staff to work in an office. Some roles require travel to employer facilities to meet with patients, staff, and providers.

Closely related fields

Here are a few nursing specialties that are similar to UR nursing. 

• Case Management (CM) nurses create and manage care plans for high-risk patients with chronic conditions such as Alzheimer’s, cancer, diabetes, and heart disease. 
• Utilization Management (UM) nurses work with facilities to respond to trends that the UR nurses identify. UM is more proactive, while UR is retrospective and reviews cases after services have been ordered or provided. 

How do you become a utilization review nurse in 3 steps?

Step 1 – Become a registered nurse

A UR nurse must first become a licensed registered nurse (RN). Although you can take a few paths, this is the most direct. 

Earn a BSN degree 

While some companies hire experienced UR nurses with nursing degrees at any level, most UR nurse positions require a Bachelor of Science in Nursing (BSN) degree. That’s why the most efficient way to become a UR nurse is to obtain a bachelor’s degree first.

There are the other pathways. 

1. If you already received your RN license from an Associate Degree in Nursing (ADN), you can enroll in an RN-to-BSN program.
2. If you have a bachelor’s degree in a field other than nursing, you should find an accelerated BSN, or ABSN, program to earn a nursing degree for utilization review.
3. A Master of Science in Nursing (MSN) is higher than a bachelor’s degree and therefore preferred by some employers.

Pass the NCLEX exam

After graduating from nursing school, you must sign up for the NCLEX exam. This exam tests knowledge needed in order to become a successful nurse. Every state requires a passing score on the NCLEX to issue an RN license. When you pass the NCLEX, you will receive your nursing license and be ready for the next step.

Step 2 – Accumulate experience

Utilization review nurses use their experience and knowledge in nursing care to promote the best use of hospital and health system resources. For this reason, most UR nurse positions require 2-5 years of RN experience in acute, inpatient settings. To be good at UR, nurses must be familiar with how things work inside the hospital. 

If you want to become a UR nurse in a specialty facility, such as a pediatric hospital, you will also need 1–3 years of specialty experience.

Helpful skills and experience

In addition to acute care experience, UR Nurses will also benefit from experience in the following:

• Working with insurance prior authorizations
• Management experience
• Billing and coding experience
• Knowledge of InterQual or Milliman

UR nurses must be familiar with insurance and even know insurance policies. So nurses who want to work in utilization review should try to understand and learn about benefits and coverages when they come up on the job.

Changing specialty to a utilization review nurse

UR nursing is different from direct care in a setting like med-surg because there is less patient interaction and more paperwork. UR nursing may be a good fit for nurses who feel burned out at the bedside and want to change specialties. In utilization review, you use your clinical skills and knowledge without some of the physical and mental demands of direct care. 

The upside is that UR nurses tend to work normal business hours, Monday through Friday, with weekends and holidays off. Nurses in UR can find greater work/life balance. Still, they may have to rotate on-call shifts. 

If you’re considering a career change, check out Incredible Health’s Nursing Career Resource page for more job tips. 

Step 3 – Obtain certifications

Here are a few specialty certifications demonstrating competency in utilization review for UR nurses. 

• The American Board of Quality Assurance and Utilization Review Physicians offers a certification for UR nurses. It is called the Health Care and Quality Management (HCQM) certification. 

• The American Society for Healthcare Risk Management (ASHRM) offers a Health Care Risk Management Certificate (HRM).

• MCG Care Guidelines offers a certification in utilization management that may benefit UR nurses called Care Guidelines Specialist in Utilization Management.

Other certifications that complement utilization review and would be helpful to have, include:

• Certified Case Manager (ACM)
• Certified Managed Care Nurse (AAMCN)
• Certified Nurse Case Manager (ANCC)

What are additional requirements of utilization review nurses? 

Since many utilization review positions are fully remote or hybrid positions, employers may have special home office requirements. To ensure nurses access facility records safely and efficiently, utilization review nurses may need

• A quiet, dedicated workspace
• High-speed wired internet connection with speed minimums (25 Mbps download,10 Mbps upload)

UR nurses who work on-site in hospitals may be required to maintain current Basic Life Support (BLS) or Pediatric Advanced Life Support (PALS) certification.

Also, depending on the nurse’s practice state, they may be required to complete a number of continuing education units each year as a condition of their RN license. 

What are the salary and career outlooks for utilization review nurses? 

According to ZipRecruiter, the average annual salary for UR nurses was $79,456 in August 2022. Top earners in the 90th percentile earned as much as $107,000. The lowest utilization review RN pay reported was around $52,000. The highest-paying cities reported for UR nurses are Atkinson, Nebraska and Frankston, TX.

The job outlook for RNs in utilization review is promising. According to the Bureau of Labor Statistics, demand for RNs is projected to increase by 6% between 2021 and 2031. Jobs in utilization tend to be secure, and there are plenty of advancement opportunities.

Job satisfaction

Job satisfaction is high in this specialty because utilization review positions offer multiple advantages like regular schedules and work predictability. 

To get career advice from nurses in the field, visit the Questions and Advice page to connect with the nursing community.

Next steps

Here are a few ways nurses in utilization review can advance their careers and gain additional opportunities. 

• Get certified! Even if you already have one certification, you can add additional credentials to show your expertise in utilization review.
• Return to school for a Master of Science in Nursing (MSN) degree with a focus on leadership or management.
• Explore an alternate degree such as business. 
• Start a consulting business.

If utilization review sounds like a good fit, what are you waiting for? Get started, and apply for UR nurse jobs today! Use this post to highlight your experience and UR-related skills on your resume, and you may just land your next nursing dream job. 

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