A Day In The Life of A Utilization Management Nurse

Utilization management probably wasn’t something you became familiar with in nursing school. In fact, it probably has the least descriptive name of all the common remote nursing job specialties. 

But it’s a big industry. There are about 55,000 utilization management nurses employed in the United States. And outside of nurses, countless other ancillary roles help to support utilization management

Here’s how one nurse, who we’ll call “Southwest nurse”, spends her time. Maybe one day, this could be you!

1. How did you know you wanted to do UM and how did you break into the field?

Southwest nurse was working at a clinic before considered doing UM, but she wasn’t looking too hard for a remote nursing job.

“I noticed that the doctors at the clinic complimented my ability to comb through a chart and take concise notes. We did a lot of phone triages at the clinic, making the transition to a remote lifestyle feel a bit more seamless.”

She got into the field through a connection. “Actually, a close friend of mine was doing UM. She thought I would be good at it, so she referred me, and that got me to the top of the applicant pool.” She wasn’t sure if she would have been as lucky without the referral. From application to start date, the entire process was only about eight weeks. 

2. What is Utilization Review or Utilization Management?

Utilization management is the process of reviewing member services and insurance claims while they are ongoing, like a concurrent hospital stay. Utilization review is the process of doing pre-authorizations or retrospective reviews, like a knee replacement.

In theory, every health insurance plan needs utilization review and management, including:

  • Medicare Advantage plans
  • Traditional Medicare, Medicaid, or federal plans
  • Commercial plans offered by employers
  • Marketplace plans
  • Third-party administrators (TPAs)
  • Independent review organizations (IROs)

3. What does a typical day look like for you?

“It’s basically the same thing every day… That’s the reality of remote nursing. If you like consistency and stability, it’s a great option. If you like excitement and change, you probably won’t.”

Here is what Southwest nurse says a typical day looks like:

1. She logs into the computer VPN system. Her computer is hard-wired into the internet, and she has two monitors and what she calls a “dinosaur phone.”

2. She logs into the review software. “It’s basically like a queue of cases that need to be reviewed. It can be overwhelming for some people because the queue can literally have over 1,000 cases in it. But that’s just the job. There will always be more insurance claims to review.”

3. She selects a case to work on. Everyone on her team works from this queue, and they all have to generally do a certain amount of cases per day to meet metrics.

4. What does a review look like?

Wondering what reviewing a case entails? Here is her answer:

1. She verifies what the review is for. This includes checking the member’s benefit plan, the requested CPT codes or diagnosis codes, and the date of service. This is also where she determines if it’s a prior authorization, concurrent review, or retrospective request.

2. She opens the case documentation. Usually, a prior authorization will be anywhere from five to 30 pages, whereas a concurrent or retrospective might be closer to 30 to 50 pages. 

3. She opens the review criteria. Most of the time, it’s MCG or InterQual, depending on what queue she is in. There are a few instances when the insurance plan has its own special criteria, if they decide to be really picky on a certain service, they don’t want to approve very often. 

4. Some reviews might require phone calls. This might be to a treating provider’s office to request additional documentation, to a hospital operator to see if a patient is still admitted, or to the hospital case management team to give an authorization or denial. All denials have to go through an MD first, so the nurse is never the sole clinician denying a health service.

5. What type of company do you work for?

“It’s a well-known insurance company,” she says. 

Here are the stats about her remote nursing job:

  • She has about 10 days of PTO a year.
  • Her company sometimes requires her to work weekends or holidays.
  • Usually, the nurses work 5 8-hour shifts, but sometimes they are allowed to work 4 10-hour shifts.
  • There is occasional mandatory overtime.
  • Overtime is almost always available if someone wants it. “Like I said, there’s always an insurance claim waiting to be reviewed.” 
  • Base pay is about $75,000 to 85,000 per year, paid hourly. She lives in the Southwest US. 
  • The 401k match is generous. 

6. How does your company track your metrics?

“We have to track how many cases we do per day, as well as ancillary actions we do that contribute to a case getting done, like phone calls or emails. Those extra tasks add up too, so if one case is taking a million phone calls, we wouldn’t have to do as many cases for that day,” she explains.

7. Is your job flexible?

“It’s not flexible in the sense that I am not able to be mobile. I am hard-wired into the internet with a hard-wired phone. So it’s not like I can go work at Starbucks. I also have to stay active on my computer all day, and I’m paid hourly, so I can’t just flex my time.” She says that it does feel flexible to be able to take her breaks on her couch or go check the mail at lunch, but it is a full and dedicated day of work.

8. What do you like to do in your free time?

“I have much more free time now that I don’t commute to work. I like to take my time making dinner almost every day. I also enjoy having time to clean my house because I’m not too tired, or just walk around my neighborhood and appreciate the nature around me.”

9. What parts of utilization management can cause burnout?

Southwest nurse says it can be hard remaining stationary all day. “I had to get a standing desk and walking pad, and I have an embarrassing amount of fidget toys. I also have a speaker to listen to music while I work, and I have a list of a bunch of podcasts, too.”

Fortunately, Southwest nurse says that nurses never have to give a denial. If something is going to be denied it will go to an MD for review. “So it’s not on my conscience if I feel like a patient isn’t getting something they need. I just go off the criteria I’m given. The MD always has the final say. But, I do know some nurses that can’t handle the denials, and it really does weigh on their spirit, which I can understand.”

10. What parts of UM are exciting to you?

“I do find the actual work itself to be fun. Once you understand UM and you get good at it, it feels very satisfying. I think of it like a puzzle. You get all the pieces together, like the clinicals and the criteria, and you just start chipping away to solve it. If you enjoy word games, you would probably like UM,” she shares.

Is Utilization Management Right For You?

UM is a great option for introverted nurses who don’t mind a slow and steady remote nursing job and work environment. Now that you know what a day in the life of a UM/UR nurse looks like, would you be willing to give it a try?
If you’re still having trouble getting your resume to stick out to recruiters, try the Nurse Fern resume template.