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What Does A Utilization Review Nurse Do?

UR nurses critically examine patient medical records, paying close attention to the appropriateness of healthcare expenditures. They rely on their experience, education, and awareness of appropriate review criteria to compile an accurate account of the patient’s clinical picture.

How much do utilization review nurses make?

Salary Ranges for Utilization Review Nurses

The salaries of Utilization Review Nurses in the US range from $14,866 to $396,665 , with a median salary of $71,350 . The middle 57% of Utilization Review Nurses makes between $71,350 and $179,694, with the top 86% making $396,665.


Is utilization review nurse stressful?

Working as a utilization review nurse can be stressful, as it may involve situations and settings in which nurses are forced to make decisions which they may not personally agree with. … Hospital nurses may also be concerned about whether or not patient cases meet the standards for reimbursement by insurance companies.

How do I become a utilization review nurse?

The minimum credentials for working in utilization review are being licensed as a registered nurse and having a good base of general nursing experience in medical-surgical nursing. Many employers require a BSN over an associate’s degree, and sometimes specific certifications in utilization review or risk management.

What is the role of utilization review?

Utilization review is a method used to match the patient’s clinical picture and care interventions to evidence-based criteria such as MCG care guidelines. This criteria helps to guide the utilization review nurse in determining the appropriate care setting for all levels of services across the arc of patient care.

Is there certification for utilization review nurse?

Utilization Review Nurse Jobs

The Certified Case Manager (ACM) certification is most common among utilization review nurses. This certification is awarded by the American Case Management Association.

Is utilization review a good job?

Utilization reviewers are being hired like crazy as payers work to prevent insurance fraud and ensure proper use of benefits. No direct patient care. If you’re looking for a truly non-clinical role, UR/UM is ideal for you. There’s zero actual patient care, but you’re still very much using your degree.

How do I become a Utilization Management Nurse?

Utilization review nurses are registered nurses, so they need to go through all the same qualifications that other nurses do. Most have a bachelor’s degree in nursing and a license from their state to practice. They also need several years of experience in patient care before switching to utilization review.

How much does Humana pay RN case managers?

Humana Salary FAQs

The average salary for a RN Case Manager is $78,651 per year in United States, which is 4% higher than the average Humana salary of $75,261 per year for this job.

How much does a legal nurse consultant make?

According to, the average salary for a legal nurse consultant can range from $55,092 to $211,399.

What is the difference between utilization review and case management?

Utilization Management vs.

The difference is that utilization management is a prospective process that occurs before and during the admission, procedure or treatment, while utilization review is retrospective.

How much does Aetna pay RN case managers?

How much does a Registered Nurse Case Manager make at Aetna, a CVS Health Company in the United States? Average Aetna, a CVS Health Company Registered Nurse Case Manager yearly pay in the United States is approximately $70,984, which meets the national average.

How do I become a utilization review?

Many employers prefer utilization review specialists who have an associate or a bachelor’s degree in a medical or health-related field, though some may consider candidates without a degree who have extensive experience in medical billing and health care quality assurance roles.

What are the two types of utilization reviews?

Utilization review contains three types of assessments: prospective, concurrent, and retrospective. A prospective review assesses the need for healthcare services before the service is performed.

What utilization review is and how it works?

Utilization review is the process of making sure healthcare services are being used appropriately and efficiently, which is a key component of a value-based approach to paying for health care.

What are the three steps in medical necessity and utilization review?

Name the three steps in medical necessity and utilization review. The three steps are initial clinical review, peer clinical review, and appeals consideration.

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