Registered Nurse (RN)

Review medical records. A utilization management nurse’s job description includes examining medical treatments and interventions to avoid payment denial and optimizing reimbursements by assessing the treatment’s appropriateness, effectiveness, timing, and setting. A prospective review occurs before treatment begins to eliminate unneeded, ineffective, or duplicate action. As treatment progresses, a concurrent review tracks resource utilization and patient progress to reduce denials. A retrospective study is then conducted to determine which treatments were successful and to ensure accurate reimbursement.  
Evaluate treatment plans. As a utilization management nurse, you’ll examine treatment plans with a critical eye. You must ensure the patient receives the best care while determining what level of treatment is necessary. You'll validate that the proposed plan aligns with established guidelines, protocols, and available resources. For instance, you may have to decide whether a patient should be admitted to the hospital, discharged to a lower level of care, or managed as an outpatient. 
Coordinate health care services. This role requires you to collaborate with other nurses, physicians, and health care providers while searching for essential information to confirm the patient’s insurer authorizes services. Many utilization management nurses work closely with case managers, or are case managers themselves.
Manage resources. Health care costs continue to rise. Identifying areas to improve the cost-effectiveness of care while maintaining quality requires reviewing the utilization of health care resources, such as the length of hospital stay, medications, therapies, and diagnostic tests. 
Work with insurance and reimbursement. The utilization management nurse works with insurance companies to provide preauthorization information. That process helps ensure that appropriate reimbursement is received, and that the organization or patient isn’t stuck with unnecessary payments. Utilization management nurses may also get involved with investigating and appealing insurance denials.
Compliance and documentation. All nurses know the importance of documentation, but it’s especially essential in nurse utilization management. Inadequate patient records can create roadblocks to care coverage. Utilization management nurses ensure that services comply with regulatory and accreditation standards. Clear documentation is also essential to maintain accurate, detailed documentation of utilization management activities and outcomes.