Utilization review (UR) jobs ensure adherence to standards of patient care. Qualifications vary, but often require experience in nursing, social work, or risk management. UR coordinators review patient records and contact insurance companies to ensure cost-effective treatment. UR directors oversee the program and monitor compliance.
The aim of utilization review (UR) papers is usually to define standards of adequacy and efficiency of patient care and to ensure that these standards are adhered to. The review may occur during and after the hours services are provided. Utilization review jobs may also include pre-employment review or discharge planning, in which case it overlaps with a similar discipline called utilization management. Most jobs covered by the UR include directors, managers, supervisors and coordinators.
Some usability review jobs may contain similar titles. For example, some employers may classify you as UR Nurse, UR Case Manager, UR Analyst, UR Specialist, or simply UR Staff. Definitions of these terms may vary by employer. Most often, specific job definitions can be found in the related job description, or the potential employer should be able to provide clarification.
Candidates for utilization review jobs may qualify through experience in nursing, social work, risk management, dental, psychiatric, or other specialized fields. Employers often require three years of related experience. A bachelor’s or master’s degree or active nursing license – registered nurse (RN) or registered nurse (LPN) – may be required, although other degrees or certificates may be accepted. Knowledge of diagnostic codes and medical insurance software is generally preferred.
Employees who work on utilization review engagements may work for companies that provide utilization review services to hospitals or institutions. They may also be employed directly by hospitals or institutions that perform their own analysis. Sometimes the professional is self-employed, working as a private contractor for a hospital or institution.
A Usage Review Director is typically the position responsible for directing all phases of the specific Usage Review program. The UR manager or supervisor typically interviews, hires, supervises, and trains employees. This position also typically monitors compliance with statutes and regulations. Prior supervisory or management experience, a degree in an applicable field, and an active nursing license are usually required.
The utilization review coordinator usually reviews patient records to ensure that treatment and length of stay are appropriate and cost-effective. If a longer stay or different treatment is required, the coordinator usually contacts the patient’s insurance company to verify continued coverage under the patient’s policy. If a conflict arises, the coordinator will usually refer it to the utilization review committee, which usually includes physicians employed by the organization.
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