Utilization Review and Management

The goal of utilization review (UR) or utilization management (UM) is to ensure patients receive quality care without unnecessary services or expenses. 

While UR and UM are similar, they focus on different points in the care journey. UR/UM nurses can help patients avoid unnecessary medical tests or procedures. They can also advocate for patients by ensuring they receive the least costly care that still serves their medical needs. 

This article will explain how to become a UR/UM nurse, including:

  • What does a UR/UM nurse do?
  • Where do UR/UM nurses work?
  • A day in the life as a UR/UM nurse
  • Background and experience for UR/UM nurses
  • Certifications for UR/UM nurses
  • Interview tips for UR/UM nurses
  • Salary ranges for UR/UM nurses
  • Pros and cons of working as a UR/UM nurse
How to transition into UR/UM remote nursing

What does a UR/UM nurse do?

A UR/UM nurse evaluates whether medical services are appropriate for a patient’s condition or situation. They make decisions using benchmarks and standardized criteria like InterQual. Complicated cases may require outreach to physicians or other providers.

Some UR/UM nurses focus on a particular type of utilization management.

  • Prospective: also known as prior authorization or precertification, this step occurs before services are provided.
  • Concurrent: reviewing the need for ongoing patient services, like a current hospital admission or therapy. This might take place in an acute care facility, a skilled nursing facility, or a rehabilitation center. Concurrent review may involve looking at patient records and speaking with relevant providers to gather information.
  • Retrospective: this might be required if a service or admission occurred without prior authorization, like admission after a visit to the ER. This could also occur as part of a regular audit.

In other words, utilization management typically deals with the beginning and active stages of the care journey. A UM nurse reviews requests for services to determine whether they are necessary, meet the coverage criteria by their insurance, and are appropriate for the level of care. 

On the other hand, utilization review takes place retrospectively after services have been provided. This may include evaluating or auditing the services provided during a hospital admission.

Other names for this career path include:

  • Nurse reviewer
  • Clinical reviewer
  • Clinical resource coordinator
  • Clinical care coordinator

A related career is case management, where nurses work closely with patients and providers to develop plans of care and ensure patients receive needed services.

My workday consists of reviewing a case after case, making callouts to the doctors offices, and receiving phone calls from doctors offices to work on cases. We are on the phone a lot, we have a certain quota of cases that we should be completing in the day. I can move around the house with my laptop, but it does make it a little harder when I don’t have my multiple monitors to work off of.

Who hires UR/UM nurses?

UR/UM nurses are in demand at health insurance organizations and other health agencies, such as:

  • Centene
  • Cigna
  • Elevance
  • UnitedHealth
  • Molina
  • BlueCross BlueShield
  • Aetna
  • Hospital and health systems
  • Government and military health providers

…and many more! Check out the Nurse Fern job board for more opportunities in UR and UM.

My advice is that it is ok to be selfish sometimes and want a healthier lifestyle while still wanting to be a nurse outside of bedside. It was very difficult for myself to transition because when people think of a nurse it’s not what I described to them that I do now, so it takes time to know if you are going to be ok with that. And UM nursing is very different and is an adjustment from what bedside nursing is yet every area of nursing will take time to feel comfortable with no matter no experience or with some. Take a chance if you have desire to go beyond beside as there are so many opportunities and bedside will always be there if non bedside was not for you.

A day in the life as a remote Utiliztion management/review nurse

UR/UM nursing is a tech-heavy job that requires you to closely monitor your task queue and work systems.

Some UR/UM nurses report that their daily tasks are set automatically by their employer to include case review time, a block of time answering the phone, and a period for meetings or training. 

For example, a UR/UM nurse may start their day with a team meeting where they review a difficult or complex case. Next, they may be assigned to answer calls from patients for two hours. Then, they have five hours to complete their daily quota of case reviews with a scheduled lunch break.

Some employers require their UR/UM nurses to work in a locked office with an ethernet connection. Many UR/UM nurses also report that they rely on a system of three monitors to complete their daily tasks. Others are able to move around their house on a laptop as long as they meet their daily quota.

There are opportunities for both shift work and standard 9-5 business hour positions. Some nurses work four 10-hour shifts and others split their time between remote work and office-based work.

I’m assigned a list of accounts and I use interqual to evaluate medical necessity for admissions and continued stays. 5x8hours work 2 saturdays a month. Never on the phone just communicate with team members via teams or email when needed . I move around the house all day take breaks etc.. only requirement is productivity of 30+ reviews a day.

Background and experience for UR/UM nurses

The good news is that it’s possible to enter UR/UM nursing without prior experience. 

Skills that can help you succeed in UR/UM include:

  • A strong clinical background: clinical experience, especially in acute care, helps nurses make good judgments about necessary services for different medical issues.
  • Tech-savvy: including a familiarity with (or a willingness to learn) tools like Slack, Zoom, and different electronic healthcare record systems
  • Good customer service: especially when explaining why certain services were approved or denied. 
  • Good time management: Many jobs in this field involve set daily or weekly quotas, so it’s important to know how to complete work efficiently without sacrificing accuracy.

It’s also helpful to have prior experience with insurance policies or preauthorization, case management experience, billing or coding experience, or knowledge of tools like Interqual, Medicare guidelines, or the Milliman Care Guidelines.

Work 8-4:30 with an hr lunch m-f, 30 minutes paid for. Paid holidays as this is a government insurance company. I review cases to determine if approved or denied. I have a laptop so can go anywhere for work. I also have multiple monitors in my office which makes things easier so I tend to work there. I can take breaks as needed. Not on the phone too frequently. Have several meeting a day but typically they are to discuss changes to regulations and discuss difficult cases with other staff and our medical directors. Its a very laid back place to work unless u have important meetings.

Certification options for Utilization review and management nurses

There are two main certification options for UR/UM nurses who are looking to advance their skills and earning potential.

Case management certifications can also be useful for nurses coming from other specialties due to some of the related skills between these professions, including:

AUX system controls your workday- not you. It assigns you your case review time, scheduled phone time, scheduled training and meetings with others, lunches and breaks. Adherence is >85% for following your Aux system schedule in Avaya. If you are off by more than 15 minutes in Avaya you then need to send an email to your manager for an adjustment since it can throw off your adherence. We have straight case review time where we are pushed cases in our platform. We are expected to have three cases open at any given time so we can bounce from one to the next to the next without stopping to meet productivity goals. You will more than likely have phone time each shift you work. These are callers (patients or MDOs requesting many different things regarding their auths) and this is normally limited to 10 minutes per call (never goes this way). Can’t move around the house on this one we use 3 monitors. A laptop, two desktop a thing that connects all together and we need all screens to function throughout the day.

Interview tips for UR/UM nurses

Nurses who are interested in moving into UR/UM nursing should highlight their previous skills and experience, such as:

  • Clinical experience, particularly in a specialty field like oncology or critical care
  • Knowledge of medical billing or coding 
  • Familiarity with utilization review criteria like Interqual or Milliman Care Guidelines
  • Prior case management experience
  • Prior experience with remote work environments, particularly when it comes to managing time independently or meeting quotas
  • Customer-service experience or prior experience with handling difficult patient conversations

Nurse Fern can help you prepare for your job search with custom resume templates and interview preparation guides. The Nurse Fern LinkedIn Course can also help you optimize your profile for maximum visibility and job search success.

I have approx 40 members that I am assigned to review at a time from admission to discharge usually averages to about 12-19 a day to get through. Have weekly rounds one day a week and huddles with my team one day a week. Other than that I am free to move around the house. I have worked there since May and I have been on the phone maybe three times with the hospitals. My team lead checks in on me once a week and my team has a group chat. I have talked to the MDs for our company a couple of times when they have questions about something I send them. I have my toddler at home with me and we have been able to potty train and I take frequent breaks to play with him.

How much do UR/UM nurses earn?

Nurses who work in UR/UM earn an average annual salary of $86,700 per year, according to Salary.com. This rate may vary based on years of experience, certifications and education, and specific job requirements.

Forms response chart. Question title: What is your salary range?. Number of responses: 31 responses. 60-65k 16.1%, 65-70k NA, 70-75k NA, 75-80k 12.9%, 80-85K 25.8%, 85-90k 9.7%, 90-95k 12.9%, 95-100k 12.9%, 100k+ no reported
Forms response chart. Question title: How many years of experience do you have in this role?. Number of responses: 33 responses. less than 1 yearr 42.4%, 1-2 years 18.2%, 2-5 years 15.2%, 5-10 years 15.2%, 10-15 years no reported, 15+ years not reported.

A small poll of the Nurse Fern community showed two interesting facts:

  • 60% had 0-2 years of experience
  • 61% earned at least $80,000 per year (including 13% who earned over $100,000 per year)

*While this is a small sample size, it does suggest that this career path has a very healthy earning potential even for newer nurses.

Pros and cons of working as a UR/UM nurse

There’s a lot to like about working as a UR/UM nurse, especially for nurses who need a break from bedside nursing. Some of the pros of working as a UR/UM nurse include:

  • The ability to work remotely from home – no more commute!
  • Great work/life balance: when your shift is over, it’s easier to mentally “clock out”
  • The chance to review and evaluate interesting medical cases
  • Opportunities for career advancement

UR/UM nurses in the Nurse Fern community generally rave about their job:

Absolutely no stress, never have to worry about work when I’m off the clock, great work- life balance. 2- 15 min breaks, and 30 minute lunch
Love that everyday is something new or different and working from home has been amazing. I was in the office prior to covid but was transitioned to wfh and given the option to stay home, work hybrid option or in the office.
I am at home; I am a constant in my children’s lives and going from work night for 5+ years my marriage is also much better with me being present!

However, working as a UR/UM nurse can be challenging in other ways:

  • May require long hours in front of a computer
  • Depending on the employer, there may be limited flexibility in how you plan your day or you may have strict quotas for case reviews
  • Can be stressful to give bad news to patients who are denied services or to deal with patients who are upset about case decisions
  • It can be lonely for nurses who enjoy the teamwork and camaraderie of bedside nursing

Are you interested in working as a remote UR/UM nurse?

Utilization review and utilization management nurses help keep healthcare costs under control. They also play a vital role in helping patients access necessary services without needless tests, treatments, or charges.

If you’re interested in a remote nursing position with great earning potential and limited patient interaction, then UR/UM nursing could be a good fit.

Go to the Nurse Fern job board to discover opportunities in UR/UM nursing. Not sure if UR/UM nursing is the right fit? Compare similar careers in data abstraction and clinical documentation integrity.