By: Leona Werezak BSN, MN, RN

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.

Part One What 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. 

Part Two What 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:

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.

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Part Three How 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!

Part Four Utilization 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.

1. Less than 1 year of experience earn an average hourly wage of $27.24
2. 1-4 years of experience earn an average hourly wage of $30.90
3. 5-9 years of experience earn an average hourly wage of $34.06
4. 10-19 years of experience earns an average hourly wage of $37.03
5. 20 years and higher years of experience earn an average hourly wage of $37.00

Highest Paying States for Utilization Review Nurses

1. District of Columbia: $42.69 per hour or $128,968 per year
2. New York: $42.66 per hour or $128,883 per year
3. California: $39.99 per hour or $120,826 per year
4. Massachusetts: $39.59 per hour or $119,608 per year
5. Washington: $39.10 per hour or $118,147per year

Via Indeed

Highest Paying Cities for Utilization Review Nurses

1. San Francisco, CA: $45.41 per hour or $137,202 per year
2. Northridge, CA: $43.23 per hour or $130,610 per year
3. San Jose, CA: $42.84 per hour or $129,437 per year         
4. Washington, DC: $42.71 per hour or $129,033 per year
5. New York, NY: $42.66 per hour or $128,883 per year

Via Indeed

Part Five Where 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 Six What 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 Seven What 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:

1. 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

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 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 

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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Part Eight Where 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.

Part Nine Utilization Review Nurse FAQs

• 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.