A nurse reviewer assesses medical records and treatments to determine if they are covered by insurance, or works on quality control issues in hospitals. Both roles require nursing training and experience, and may involve travel. Patients can appeal denials if they feel treatment was appropriate.
A reviewer nurse is a nurse who reviews medical records and proposes treatments to determine if they are covered by insurance. This term is also used to refer to a slightly different nursing career as a nurse reviewer in a hospital working on quality control issues. Both professions require nursing training and experience to familiarize professionals with the hospital environment, as well as the standards of care in the hospital environment. They may require travel and may bring benefits such as health care and retirement accounts.
In the case of a nurse reviewer who works with an insurance company, the nurse reviewer looks at patient records to review the treatments provided to the patient. If the treatments appear to meet the standards set by the insurance company, they will be approved for payment. Records of treatments not approved or endorsed by the insurance company will be rejected for payment on the grounds that the treatments provided go beyond the scope of cover provided by the insurance.
Nurse reviewers travel to physicians’ offices and hospitals and can also be seen in home care settings, reviewing treatments provided to patients who receive care at home. Your job requires maintaining current standards of care in medicine, as well as being familiar with insurance company policies. A physician may also work with a reviewing nurse to develop a course of treatment that will be approved by the insurance company. Patients can appeal denials if they feel that treatment was the only appropriate option.
Quality control with a nurse reviewer involves retaining a nurse or a team of nurses to review patient records in a hospital, clinic, or other care facility. They look for signs of quality problems, such as unusually high rates of complications, risky behavior, and so on. This information is used to generate policy and practice recommendations aimed at maintaining high standards of care. Hospitals that use nurses for quality control tend to have better patient outcomes and may be eligible for awards and other recognition.
For this type of nursing reviewer work, the nurse usually works in a fixed environment, sometimes outside the office, reviewing patient records and compiling data. There are training programs available to provide nurses with quality control skills, and nurses can use software programs to compile and process data. Experience with patient care is important for people in these jobs, as they have skills and experience gained from working directly with patients.
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