Utilization review registered nurses (RNs) find the most effective use of a patient's insurance coverage and balances it with doctor's recommendations, hospital care costs and other medical considerations. These professionals help ensure that a patient gets the best possible care within the dictates of financial and insurance guidelines. Like other RNs, these professionals need to hold diplomas or degrees in nursing. They can pursue additional education through certificate programs in medical case management.
|Required Education||Diploma, associate's degree or bachelor's degree in nursing; completion of a medical case management or related certificate|
|Projected Job Growth (2012-2022)||19% for all RNs*|
|Median Salary (September 2014)||$62,608 annually for utilization review RNs**|
Sources: *U.S. Bureau of Labor Statistics, **PayScale.com
Education Requirements for a Utilization Review RN
Bachelor of Science in Nursing
A utilization review registered nurse must first fulfill the education and licensing requirements of a RN, including a degree in nursing and successfully passing the National Council Licensure Examination for registered nurses (NCLEX-RN). Though nursing degree programs are available as both associate's and bachelor's degrees, employers may prefer utilization review nurses to have at least a bachelor's degree. Bachelor of Science in Nursing programs typically include classes in anatomy, microbiology, psychology, chemistry, pharmacology and medical terminology.
Medical Case Management Certificate
After gaining experience as a registered nurse, prospective utilization review nurses may enroll in a certificate program in medical case management or health care risk management to learn more about the utilization review process. These programs typically require applicants to already be an RN or another medical professional. These programs typically include coursework in patient safety, clinical ethics, risk management, medical insurance and health care standards.
Utilization review nurses review the risks and liabilities for hospital and clinic patients. They review potential medical procedures and serve as a liaison between patients, care providers and insurance companies. Utilization review registered nurses may work in a variety of settings, including hospitals and other medical care facilities, as well as insurance companies and nursing homes.
A utilization review RN should have a firm understanding of insurance procedures and how they work in conjunction with hospital or facility policies. A survey of various job postings for this position shows that many facilities hiring utilization review RNs prefer experience in a like facility, such as acute care, home health care and emergency care. Expertise in state, federal and third party payment regulations may also be beneficial, as well as good communication and computer skills.
In September 2014, Payscale.com showed the salary for utilization review RNs ranged from $49,109 to $85,340 annually. The BLS reported that median annual salaries for RNs were $66,220. Ground passenger transportation and other transit systems typically offered the potential for the highest pay. The BLS also indicated that California and Hawaii were the states offering the highest pay on the upper end of the salary ranges.