A utilization review (UR) nurse is a registered nurse who evaluates whether the care a patient receives is medically necessary, appropriate, and cost‑effective, often acting as a bridge between providers and insurance plans. The role is largely non–bedside and is common in hospitals, insurance companies, managed‑care organizations, and many remote/work‑from‑home positions.
What UR nurses do
- Review medical records to determine if tests, procedures, admissions, or length of stay meet evidence‑based criteria and payer policies for “medical necessity.”
- Communicate with physicians, case managers, and insurance representatives to obtain authorizations, clarify documentation, and coordinate continued stay or discharge plans.
- Handle pre‑authorizations, concurrent reviews during a hospitalization, and retrospective reviews after discharge to support proper reimbursement and avoid denials.
Skills and background needed
- Active RN license (ADN or BSN) plus typically 2–3 years of recent clinical experience, often in acute care (ICU, ED, med‑surg, etc.).
- Strong chart review, critical thinking, and attention to detail, with comfort using EMRs and clinical criteria tools such as MCG or InterQual.
- Excellent written and verbal communication, plus working knowledge of insurance, utilization criteria, and basic regulations around coverage and patient rights.
Typical work environment
- Employers include health insurers, hospitals/health systems, managed‑care or revenue‑cycle companies, and government payers such as Medicare/Medicaid contractors.
- Many roles are office‑based or fully remote, focused on screen‑based chart review, emails, and calls instead of direct patient care.
- The schedule is often more predictable than bedside nursing, though productivity expectations (number of reviews per day) can be high.
How to move into UR
- Gain solid acute‑care experience and emphasize assessment, documentation quality, and interdisciplinary collaboration on your resume.
- Look for job postings using terms like “utilization review nurse,” “utilization management nurse,” “clinical review nurse,” or “medical necessity reviewer,” including remote listings.
- Consider certifications in case management or healthcare quality (for example, CCM or CPHQ) to strengthen your application, especially if you lack prior UR experience.
If you share your current experience and goals (bedside vs remote, specialties, years of practice), a tailored step‑by‑step plan for breaking into utilization review can be outlined.