A utilization review nurse speaks with patients and doctors to determine whether medical insurers are paying for the right amount of care. Utilization review is a part of the independent medical exam process, where third parties assess whether a health insurer’s benefits should be paid out. This is also referred to as medical peer review or independent medical exam (IME). Utilization review nurses may work in hospitals, clinics, insurance companies and other medical firms that administer in-home care.
As a utilization review nurse, it is your job to ensure that health care services are reimbursed appropriately. Your job requires accuracy and speed, as you’ll be reviewing patients’ medical records and making sure they meet coverage requirements. You may need to work with different doctors, hospitals and insurance companies.
The utilization review nurse is responsible for ensuring that patients discharged from a facility lead healthy and productive lives. Utilization review nurses often work on teams that are tasked with identifying indicators of poor health in patient records.
How To Become A Utilization Review Nurse
So you want to become a utilization review (UR) nurse? It’s a great career choice! UR nurses are in demand, and the job outlook is good.
This article will explain everything you need to become a utilization review nurse, including education requirements, job duties, and salary range.
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ACCREDITATION
CCNE
LOCATION
Online
PREREQUISITE
RN Required
Enrollment: Nationwide, excluding IA, IL, WI
Bachelor of Science in Nursing – RN-to-BSN
Bachelor of Science in Nursing – RN-to-BSN – ExcelTrack™
Purdue University Global
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Walden’s online programs for nursing meet rigorous standards for academic quality and integrity, and the School of Nursing teaching faculty all hold doctorates. With three degree completion options, you can choose a bachelor’s in nursing path that makes sense for your busy, unpredictable schedule.
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ACCREDITATION
CCNE
LOCATION
Online
PREREQUISITE
RN Required
Enrollment: Nationwide, excluding AK, ID, MA, NH, NY, OK, OR, RI, SD
Bachelor of Science in Nursing (RN-BSN)
Walden University
Learn More
GCU’s RN-BSN program is tailored to meet the needs of the RN adult learner and to maximize the strengths that the working RN already possesses. Transfer up to 90 credits and earn a BSN in as little as 12 months. GCU’s online classes allow you to study at the times that work for your schedule while still enjoying a close connection with your classmates and instructor via online discussions.
Show more
ACCREDITATION
CCNE
LOCATION
Online
PREREQUISITE
RN Required
Enrollment: Nationwide
Bachelor of Science in Nursing (RN to BSN)
Grand Canyon University
Learn More
The University of Texas at Arlington’s online programs are designed to help you achieve more in your nursing practice with a Bachelor of Science in Nursing. They offer convenient, flexible options for completing your RN to BSN online, designed to fit into your busy schedule.
Show more
ACCREDITATION
CCNE
LOCATION
Online
PREREQUISITE
RN Required
Enrollment: Nationwide
RN to BSN
The University of Texas at Arlington
Learn More
PART ONEWhat Is a Utilization Review Nurse?
A utilization review (UR) nurse is a registered nurse (RN) who is responsible for ensuring that patients receive the care they need while also preventing unnecessary or duplicate services.
The goal of utilization review nursing is to maximize the quality of patient care while also minimizing costs.
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PART TWOWhat Do Utilization Review Nurses Do?
UR nurses work with patients, families, and healthcare staff to make sure that everyone is on the same page regarding the care plan. They also work with insurance companies to ensure coverage for the services provided.
UR nurses play an important role in the healthcare system by making sure that patients receive the care they need cost effectively.
Skills UR Nurses Need to Have
The role of utilization review nurses has evolved over time, and today’s UR nurses must be able to effectively navigate the complex world of health insurance.
UR nurses have to have a strong understanding of the various types of coverage available and be able to advocate for patients and their families.
UR nurses must also be proficient in using technology, as they will often be required to use electronic health records (EHRs) and other computer-based systems.
UR nurses must be able to:
Work independently
Stay calm in chaotic situations
Set clear boundaries with patients and their families
Navigate complex paperwork
Make sound decisions in a fast-paced environment
UR Nurse Duties by Place of Work
UR nurses typically work full-time hours in hospitals, but some may also work in private practices or insurance companies.
Depending on the setting in which they work, UR nurses may have different job duties. For example, those working from home may be responsible for conducting chart reviews and writing reports, while those working in a hospital may be responsible for interacting with patients and their families.
Regardless of the setting, all UR nurses are responsible for ensuring that patients receive the care they need in a cost-effective way.
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PART THREEHow to Become a Utilization Review Nurse
Step 1: Enroll in a Nursing Program
To become a UR nurse, you must first obtain an Associate’s Degree in Nursing or ideally a Bachelor of Science in Nursing. Many schools offer pre-licensure Bachelor of Science in Nursing (BSN) programs, which take 4 years to complete. Some UR nurses have also completed a master’s degree in nursing.
Step 2: Pass the NCLEX-RN
Sit and pass the NCLEX-RN licensure exam. This is the licensing exam set forth by the National Council of State Boards of Nursing (NCSBN) and is a requirement to legally practice as an RN in all states.
Step 3: Gain Experience
Find a job where you can work full-time hours as an acute care nurse for at least 2-3 years.
Step 4: Do Your Research
Look for a UR nurse position(s) that you would like to work in and find out what UR certification and work experience they require.
Step 5: Meet the Requirements
Once you have the required nursing education and nursing experience, you’ll need to obtain certification as a utilization review nurse (3-4 months) and complete the other requirements needed for the UR nurse position you’re interested in. Then you can apply for utilization review nurse jobs!
We Found the Following Schools with Online RN-to-BSN Programs
Sponsored
At Purdue Global, discover a faster, more affordable way to earn your Nursing degree. Purdue Global is committed to keeping your tuition costs as low as possible and helping you find the most efficient path to your degree.
Show more
ACCREDITATION
CCNE
LOCATION
Online
PREREQUISITE
RN Required
Enrollment: Nationwide, excluding IA, IL, WI
Bachelor of Science in Nursing – RN-to-BSN
Bachelor of Science in Nursing – RN-to-BSN – ExcelTrack™
Purdue University Global
Learn More
Walden’s online programs for nursing meet rigorous standards for academic quality and integrity, and the School of Nursing teaching faculty all hold doctorates. With three degree completion options, you can choose a bachelor’s in nursing path that makes sense for your busy, unpredictable schedule.
Show more
ACCREDITATION
CCNE
LOCATION
Online
PREREQUISITE
RN Required
Enrollment: Nationwide, excluding AK, ID, MA, NH, NY, OK, OR, RI, SD
Bachelor of Science in Nursing (RN-BSN)
Walden University
Learn More
GCU’s RN-BSN program is tailored to meet the needs of the RN adult learner and to maximize the strengths that the working RN already possesses. Transfer up to 90 credits and earn a BSN in as little as 12 months. GCU’s online classes allow you to study at the times that work for your schedule while still enjoying a close connection with your classmates and instructor via online discussions.
Show more
ACCREDITATION
CCNE
LOCATION
Online
PREREQUISITE
RN Required
Enrollment: Nationwide
Bachelor of Science in Nursing (RN to BSN)
Grand Canyon University
Learn More
The University of Texas at Arlington’s online programs are designed to help you achieve more in your nursing practice with a Bachelor of Science in Nursing. They offer convenient, flexible options for completing your RN to BSN online, designed to fit into your busy schedule.
Show more
ACCREDITATION
CCNE
LOCATION
Online
PREREQUISITE
RN Required
Enrollment: Nationwide
RN to BSN
The University of Texas at Arlington
Learn More
PART FOURUtilization Review Nurse Salary
According to the U.S. Bureau of Labor Statistics (BLS), the median salary for a registered nurse in 2021 is $77,600 per year or $37.31 per hour. While the BLS does not differentiate between different specialties of nursing, Salary.com reports that the average utilization review nurse salary is $85,100, with a salary range of $75,600 to $93,900. Overtime pay typically averages another $9000 per year.
Utilization Review Nurse Salary by Years of Experience
Specifically, UR nurses can earn a higher annual salary with increased years of experience.
Less than 1 year of experience earn an average hourly wage of $27.24
1-4 years of experience earn an average hourly wage of $30.90
5-9 years of experience earn an average hourly wage of $34.06
10-19 years of experience earns an average hourly wage of $37.03
20 years and higher years of experience earn an average hourly wage of $37.00
Highest Paying States for Utilization Review Nurses
District of Columbia: $42.69 per hour or $128,968 per year
New York: $42.66 per hour or $128,883 per year
California: $39.99 per hour or $120,826 per year
Massachusetts: $39.59 per hour or $119,608 per year
Washington: $39.10 per hour or $118,147per year
Via Indeed
Highest Paying Cities for Utilization Review Nurses
San Francisco, CA: $45.41 per hour or $137,202 per year
Northridge, CA: $43.23 per hour or $130,610 per year
San Jose, CA: $42.84 per hour or $129,437 per year
Washington, DC: $42.71 per hour or $129,033 per year
New York, NY: $42.66 per hour or $128,883 per year
Via Indeed
PART FIVEWhere Can a Utilization Review Nurse Work?
UR nurses can work in a variety of settings, including hospitals, insurance companies, and government agencies. In each of these settings, these nurses use their clinical knowledge to ensure that patients are receiving the most appropriate care possible.
For example, they may review patient records to identify unnecessary tests or procedures. They may also meet with patients and families to discuss treatment options and make sure that they understand their rights and responsibilities.
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PART SIXWhat Is the Career Outlook for a Utilization Review Nurse?
The job outlook for UR nurses is excellent and the demand for their services is increasing.
UR nurses help to save healthcare costs by ensuring that patients receive the most appropriate care. As the healthcare system continues to evolve, UR nurses will play an increasingly important role in improving patient outcomes while reducing costs.
The demand for utilization review nurses is expected to grow by 12% between 2018 and 2028 creating 371,500 new jobs across the U.S. as health care costs continue to rise and healthcare organizations look for ways to provide more cost-effective care.
Find a job as a Utilization Review Nurse! Check out the nurse.org job board for the latest nursing jobs in your area.
PART SEVENWhat are the Continuing Education Requirements for a Utilization Review Nurse?
There isn’t one specific certification required to be a UR nurse. Because of this, it’s a good idea to consider acquiring certifications in a few different areas such as patient care coordination, health care planning, and case management to increase your chances of landing work in this nursing specialty.
Some certifications that qualify include:
- Nursing Case Management Certification (CMGT – BC)
This certification is offered by the American Nurses Credentialing Center (ANCC) and remains valid for 5 years. The recertification process begins while your certification is still current and requires:
Completion of 75 continuing education contact hours (CH)
Completion of at least one (1) of 8 certification renewal categories
Payment of the renewal fee
- Certification in Healthcare Quality and Management (HCQM)
Offered by the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP), this credential must be recertified every 2 years and requires:
Completion of at least “8 CME/CE credit hours of continuing education as relevant to the fields of Healthcare Quality and management per 2-year recertification cycle”
Remaining current with all account balances
- Healthcare Risk Management Certificate (HRM)
The American Society for Healthcare Risk Management (ASHRM) offers this 3-module course. Students earn 13 contact hours towards Continuing Nursing Education (CNE) requirements for each completed module. Recertification of this credential is not indicated on the ASHRM site.
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PART EIGHTWhere Can I Learn More About Utilization Review Nurses?
You can learn more about what’s required of UR nurses by speaking with the quality improvement and case management departments of the facility where you work.
