How to Become a Utilization Review (UR) Nurse

Pursuing a career as a utilization review (UR) nurse is a professionally and personally rewarding decision. UR nurses are in demand, well-paid healthcare professionals who help provide prompt, cost-effective care to patients nationwide.

In this article, we'll explore how to become a utilization review nurse, including education requirements, job duties, and salary potential. Continue reading to learn more about what it takes to enter the exciting world of UR nursing.

A utilization review nurse is a registered nurse (RN) who is responsible for ensuring patients receive necessary care without performing unnecessary or duplicate services. The goal of utilization review nursing is to maximize the quality of patient care and cost-effectiveness.

UR nurses ensure the highest quality of patient care through systematic reviews of the patient's medical records and active communication with the patient, family members, and healthcare teams to recommend the most appropriate services and treatments. They also work with insurance companies to ensure coverage for the services provided. 

Utilization review nurses play an important role in the healthcare system by ensuring patients receive the care they need cost-effectively.

Utilization Review Nurse Skills & Competencies

The role of utilization review nurses has evolved over time, and today's UR nurses must be able to navigate the complex world of health insurance effectively. They must also understand the various types of coverage available and advocate for patients and their families. 

Additionally, UR nurses should 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:

1. Work independently
2. Stay calm in chaotic situations
3. Set clear boundaries with patients and their families
4. Navigate complex paperwork
5. Make sound decisions in a fast-paced environment

UR Nurse Duties by Workplace

UR nurses typically work full-time hours in hospitals, but some may also work in private practices or insurance companies.

UR nurses may have different job duties depending on the setting in which they work. 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 patients receive the care they need cost-effectively.

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Step 1: Enroll in a Nursing Program

To become a UR nurse, you must first obtain an Associate 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 four years to complete. Some UR nurses have also completed a Master of Science in Nursing (MSN) degree. 

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 practice legally as an RN in all states.

Step 3: Gain Experience

Before becoming eligible for a utilization review position, you'll need at least 2-3 years of relevant clinical experience, ideally in an acute care setting.

Step 4: Obtain Utilization Review Nurse Certifications

While clinical nursing experience will go a long way, you still need to prepare for your role as a UR nurse. Try researching UR nursing jobs near you to discover which certifications employers prefer.

As you identify which credentials you'll need, you can prepare for them by studying for exams and completing the required paperwork. Keep in mind that obtaining UR nursing certifications can take an average of 3-4 months.

Step 5: Find a UR Nursing Position

You can begin working as a utilization review nurse once you've amassed enough experience and the proper credentials. To land a top position, refine your nursing resume and take plenty of time to prepare for the interview.

Utilization review nurses earn an average annual salary of $90,700 or $44 per hour in 2024, according to Salary.com. However, overtime shifts can increase this annual salary by another $9,000. These estimates slightly exceed the median annual RN salary of $86,070 or $41.38, as reported by the US Bureau of Labor Statistics (BLS). 

Utilization Review Nurse Salary by Years of Experience

Often, UR nurses earn higher salaries over time. Here's an average overview of how a UR nurse's salary may increase with years of experience:

1. Less than 1 year of experience: $70,228 per year
2. 1-4 years of experience: $71,167 per year
3. 5-9 years of experience: $74,187 per year
4. 10-19 years of experience: $77,657 per year
5. 20 or more years of experience: $80,027 per year

Source: Payscale, Accessed 26 June 2024

Highest Paying States for Utilization Review Nurses

State	Annual Salary	Hourly Wage
Massachusetts	$103,009	$49.52
Washington	$98,490	$47.35
Colorado	$96,973	$46.62
Delaware	$90,959	$43.73
New York	$90,649	$43.58

Source: ZipRecruiter, Accessed 26 June 2024

Highest Paying Cities for Utilization Review Nurses

City	Annual Salary	Hourly Wage
Berkeley, CA	$114,573	$55.08
La Honda, CA	$111,988	$53.84
Bumpass, VA	$111,472	$53.59
Los Altos, CA	$109,866	$52.82
Bailey's Crossroads, VA	$108,946	$52.38

Source: ZipRecruiter, Accessed 26 June 2024

UR nurses can work in various settings, including hospitals, insurance companies, and government agencies. In these settings, these nurses use their clinical knowledge to ensure patients receive 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 ensure they understand their rights and responsibilities. 

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The job outlook for UR nurses is excellent, and the demand for their services is increasing. 

UR nurses help save healthcare costs by ensuring 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 6% between 2018 and 2028, creating 195,400 new jobs across the US as healthcare costs continue to rise and healthcare organizations look for ways to provide more cost-effective care. These estimates are similar to the career outlook for all RNs, which is 6% from 2022 to 2032, according to the BLS.

Find a job as a Utilization Review Nurse! Check out the nurse.org job board for the latest nursing jobs in your area.

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:

1. Nursing Case Management Certification (CMGT - BC)

The American Nurses Credentialing Center (ANCC) offers this certification, which is valid for five years. You should begin the recertification process while your original credential is still current. The CMGT - BC recertification requirements include the following: 

• Completion of 75 continuing education contact hours (CH)
• Completion of at least one (1) of 8 certification renewal categories
• Payment of the renewal fee

2. 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 two years. The HCQM recertification guidelines include the following requirements:

• Complete "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 

3. 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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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.

• Is utilization review nursing stressful?

  • Yes, utilization review nursing can be stressful because it ensures patients receive the appropriate level of care. This includes ensuring that patients receive the treatment they need and aren't receiving care they aren't eligible for. UR nurses often feel stressed and frustrated in these situations as they try to advocate for their patients while following insurance and facility guidelines.

• What is utilization review in healthcare?

  • Utilization review is a process that compares a patient's clinical picture and care actions to evidence-based care guidelines. These guidelines assist a UR nurse in evaluating the appropriate treatment and care setting for a patient’s healthcare trajectory.

• What is the difference between UR and UM?

  • Utilization reviews (UR) are conducted on patient data and medical records to determine whether or not patients received comprehensive and correct treatment and services. UR also protects against unwarranted medical care. Utilization management (UM) ensures that healthcare systems improve and provide appropriate levels of treatment based on information obtained from UR, thereby reducing the likelihood of cases requiring evaluation for ineffective or needless treatment.

• Is utilization review the same as case management?

  • Utilization review (UR) and case management (CM) are closely related but distinct concepts. Both involve ensuring patients cost-effectively receive the best possible care but differ in scope and focus. UR is primarily concerned with the medical necessity of care and treatment services. UR nurses ensure that patients receive only those services that are clinically appropriate and necessary for their condition. In contrast, case managers take a more holistic approach to patient care and look at all aspects of a patient's situation to ensure they get the coordinated care they need. 

$70,000 - $90,000 Associate Bachelors Non-Bedside RN Utilization Review