Curious about the Nurses and Doctors in the Utilization Review Community?

| | Utilization Review

The Utilization Review (UR) industry relies on a network of passionate, qualified, and knowledgeable nurses and doctors to successfully manage treatment options for patients. Nurses and doctors who are interested in joining the UR community need to have or develop certain characteristics, experience and expertise.

UR Nurses: Expertise, Inquisitive Nature, and an Eye for Detail

1. Experience

Most UR organizations require that nurses demonstrate a certain level of nursing skill and experience. Most organizations will require nurses to have at least 12 months of experience working as a nurse, if not more. Many UR organizations are also looking for experience in the particular field in which they will be performing UR. For example, a nurse hired to handle UR for pediatric cases may be required to have previous pediatric experience. For nurses conducting workers’ compensation UR, the better candidates tend to come from orthopedic, surgical or emergency room settings as they have more experience with the types of musculoskeletal injuries that comprise most workers’ comp cases.

2. Inquisitive Nature

Effective UR nurses are typically curious and inquisitive. Much of UR is like putting together the pieces of a puzzle: UR nurses look at a patient’s history, the conditions surrounding the injury, and the appropriate treatment guidelines, in order to make decisions about treatment requests. It helps, then, for nurses to be naturally inquisitive, which will drive them to seek out the best information and solve problems to the best of their abilities.

3. An Eye for Detail

Part of a UR nurse’s job to understand and adhere to state regulations. They must also thoroughly comprehend the nuances and complexities of treatment guidelines. For these reasons, UR nurses need to be detail oriented.

4. Passion for Medicine

Of course, any nurse who wants to work within the UR community should be passionate about medicine. UR is a time-consuming and complex process, and nurses must care deeply about ensuring proper patient care in order to succeed.

UR Doctors: Experience, Personality and Diplomacy

1. Experience

Just like UR nurses, UR doctors need to demonstrate a high level of medical expertise. The Utilization Review Accreditation Commission dictates that most UR physicians have at least five years of experience. Because most workers’ compensation cases involve musculoskeletal injuries, it is best for UR doctors to have experience in areas that treat these types of injuries. This is why physical medicine/rehab specialists, orthopedic surgeons, neurologists/neurosurgeons, general surgeons and internal medicine practitioners tend to make great peer reviewers. While specialty can make a difference, doctors in all fields can be great UR peer reviewers. Generally, the best reviewer for any case is a reviewer who has experience treating that particular type of injury, and who is knowledgeable about evidence-based medicine.

2. Personality

Doctors with the necessary experience to enter the UR industry should also consider whether they have the right personality to be a peer reviewer. These doctors must have constructive, respectful and potentially challenging peer-to-peer conversations about treatment options. Doctors who enjoy interacting and helping their peers may have the right personalities to serve as peer reviewers. Doctors who have retired from their own practices but who still want to use their medical expertise often make great peer reviewers. For example, a surgeon who may no longer be able to use his physical skills to operate may put his knowledge and experience to work as a peer reviewer.

3. Diplomacy

Peer reviewing requires a fair amount of diplomacy skills. When treatment disagreements occur, peer reviewers must be able to explain to other physicians tactfully and clearly why the guidelines disagree with treatment requests. Diplomacy is especially important for UR medical directors, who must often explain to both claimants and requesting physicians, why certain treatments were denied. These two profiles provide interested doctors and nurses insight into joining the UR community and what it takes to be successful in the industry. Doctors and nurses who meet these requirements can take the next step and contact UR organizations to learn more about these opportunities.

Karen Atkins

Karen Atkins, Chief Operating Officer with UniMed Direct, is leading the conversation, and the industry, on how to make the utilization review process more efficient for all stakeholders: physicians, insurance companies and, most importantly, patients.