Utilization Review Nursing
It’s a beautiful Saturday morning, and while all others are enjoying their TGIS (Thank God It’s Saturday) weekend, Nurse Jenna is busy preparing to go on morning duty shift. She checks her reflection in the mirror one last time to make sure that she is presentable and neat and heads out the door to face another toxic day at the hospital.
She has been working as a Ward Nurse for about 2 years now, doing bedside care, administering medications, and performing different kinds of nursing procedures. She has met patients with different cases and from all walks of life. In those two years working inside the four walls of the hospital, she has learned a lot, however, in those years, she has also been exposed to all kinds of diseases.
She sighs, no matter how fulfilling the work of a ward nurse is, there come times that she just feels stressed out and tired. Facing patients and catering their various needs everyday can sometimes be draining. She wonders how it is working behind the scenes? Like doing office work and just facing papers instead of people every day. Is there eve a job like that for nurses? If there is, then she would want to try it some time.
A utilization review nurse is a registered nurse who reviews individual medical cases to confirm that they are getting the most appropriate care and may work for insurance companies, determining whether or not care should be approved in specific situations, and they can also work in hospitals.
If you are one, your goal is to balance the needs of a patient with the need to reinforce policies, keep costs reasonable, and ensure that patients are provided with medical treatment which is suited to their situation. In other words, they work to maximize the quality and cost efficiency of health care services.
Their duties include ensuring that patients receive the care they need without burdening the health care system with unnecessary procedures, ineffective treatments or overlong hospital stays through conducting regular reviews and audits. They also help the insureds to make informed decisions about their health care by educating them on the benefits and limitations of their Medicare, Medicaid or private health care coverage.
How to Become a Utilization Review Nurse
After reading the overview about this specialization, you have come to consider applying to become one. But how does one really become a utilization review nurse? What are needed? What steps must one undertake?
Just like any other specialization in nursing, aspirants must first obtain a degree in nursing where they could learn about general patient care and administrative duties as they pertain to nursing and after which, take and pass the National Council Licensure Examination for Registered Nurses (NCLEX-RN). Also, they must receive training in utilization review management and next pass a certification examination. Topics such as patient safety, risk management and health assessment can prepare individuals to become utilization review nurses.
After becoming a registered nurse through passing the NCLEX-RN, individuals who wish to become a utilization review nurse must complete additional training such as those certificate programs in health care risk management or case management which may introduce those who already work in the field of health care to the basic concepts, techniques, and purpose of health assessment and management. Here, they will learn how to improve quality assessment reporting by defining and describing utilization review plans and understanding how to file and report case management claims.
Since utilization review holds accountability of patient care, employers may require the aspiring utilization review nurses to be certified. There are organizations such as the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP) that offer Health Care Quality and Management (HCQM) Board Certification to nurses working in utilization management. Certification is then granted once an examination is completed successfully.
Those nurses who are interested in specialized work such as utilization review for prisoners or members of the military may need to pass background checks and fulfill other requirements before they can start work.
Nursing is not just limited to rendering care at the bedside. With new innovations, a lot of changes has been made possible and you can now choose a specialization (such as utilization review nursing) which is close to your heart and interests.