A utilization review (UR) nurse, also known as a utilization management nurse, is a registered nurse who must decide what level of care is necessary and appropriate for patients within her area of responsibility. Most UR nurses work for health care insurers or large health care institutions, such as hospitals and nursing homes. They are routinely faced with potentially life-altering decisions to either approve or reject a specific mode of treatment, diagnostic test or medication. Such decisions may cover health insurers’ policyholders, as well as uninsured or underinsured patients in a managed care environment.
A basic tenet of all jobs in health care and medicine is to give top priority to the needs of the patient. Managed care requires many medical professionals, including UR nurses, to make tough decisions that require balancing the cost of care against basic obligations to the patient. In an article written for a 2004 issue of NurseWeek, Glen Fest said such decisions test the ethical resolve of UR nurses on a daily basis. “They weigh their responsibility to patient need against medical necessity provisions under managed care organizational guidelines, and provide the ‘yea’ or ‘nay’ on medical procedures.”
Responsibilities & Duties
Diane Huber, Ph.D. and R.N., an associate professor of case management and nursing administration at the University of Iowa, sums up the responsibilities of the UR nurse as follows: Match patient care needs to available resources, ensure that they stay at appropriate levels and make adjustments if necessary. She adds, “Probably the most difficult aspect for any care provider is when you come upon that point where an insurance policy or whatever form of reimbursement—whether it's Medicare or whether it's private or anything else—might not be covering certain aspects of care."
Qualitative & Educational Requirements
Personal qualities that are desirable in UR nurses include the ability to work under stress, both with and without supervision; attention to detail and a tolerance for handling large amounts of data; ability to quickly analyze and interpret data; and decisiveness. All candidates must have a registered nursing degree, preferably at the baccalaureate level, as well as some experience in the field of case management and/or utilization review.
Job prospects for UR nurses—and registered nurses in general—are very bright, according to the Occupational Outlook Handbook published by the U.S. Bureau of Labor Statistics (BLS). The total number of registered nurses, estimated at 2.5 million in 2006, is predicted to rise 23 percent to almost 3.1 billion by 2016. More rapid growth is predicted in the number of registered nurses working at home health care services, with a rise of 39 percent, and outpatient care centers, with a 34 percent increase expected.
Indeed.com estimates that the average annual earnings of UR nurses were $74,000 as of late 2009. This is considerably higher than the mean annual earnings of all registered nurses, a figure estimated by the BLS at $65,130 in the spring of 2008.