How to Become a Utilization Review (UR) 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.

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 make recommendations about what services and treatments are most appropriate. 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 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:

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 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.

>> Show Me Online RN-to-BSN Programs

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 four 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 practice legally 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 certifications and work experience they require.

Step 5: Meet the Requirements

After completing your nursing education and experience, you'll need to obtain certification as a utilization review nurse, which takes an average of 3-4 months. During that time, you may complete any other UR nursing requirements you discovered during the research step. After that, you can begin applying for utilization review nurse jobs!

According to the US Bureau of Labor Statistics (BLS), the median salary for a registered nurse in 2022 is $81,220 per year or $39.05 per hour. While the BLS does not differentiate between different specialties of nursing, Salary.com reports that the average utilization review nurse salary is $89,200, with a salary range of $79,300 to $98,500. Overtime pay typically averages another $9000 per year. 

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: $70,993 per year
3. 5-9 years of experience: $73,233 per year
4. 10-19 years of experience: $75,687 per year
5. 20 or more years of experience: $77,067 per year

Via Payscale

Highest Paying States for Utilization Review Nurses

1. Washington: $96,239 per year; $46.27 per hour
2. New York: $93,302 per year; $44.86 per hour
3. Massachusetts: $88,336 per year; $42.47 per hour
4. Missouri: $87,475 per year; $42.06 per hour
5. Hawaii: $86,631 per year; $41.65 per hour

Via ZipRecruiter

Highest Paying Cities for Utilization Review Nurses

1. Albuquerque, NM: $151,916 per year; $50.28 per hour
2. Southfield, MI: $134,397 per year; $44.48 per hour
3. Fort Lauderdale, FL: $133,795 per year; $44.28 per hour
4. Boston, MA: $125,620 per year; $41.58 per hour
5. Philadelphia, PA: $122,746 per year; $40.63 per hour

Via Indeed

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. 

>> Show Me Online RN-to-BSN Programs

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 US as healthcare 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.

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)

This certification is offered by the American Nurses Credentialing Center (ANCC) and remains 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.

>> Show Me Online RN-to-BSN Programs

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 the nurse is often in charge of ensuring that patients receive the appropriate level of care. This includes making sure that patients receive the treatment they need, but also that they aren't receiving care that they aren't eligible for. In these situations, nurses can often feel stressed and frustrated 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 health care 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 medical care that is unwarranted. 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 two closely related but distinct concepts. Both involve ensuring that patients receive the best possible care in a cost-effective manner, but they differ in terms of scope and focus. UR is primarily concerned with the medical necessity of care and treatment services. UR nurses work to 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 are getting the coordinated care they need. 

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