What Makes a Great Utilization Review Nurse?

| | Utilization Review

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What distinguishes a great utilization review nurse from a good one? Three traits set the great ones apart: passion and compassion, attention to detail and solid clinical experience.

1. Passion and Compassion

Great utilization review nurses have passion for medicine and compassion for their patients. In workers’ comp, those patients are injured workers.

Whether working in a hospital or at a desk, great nurses understand the potentially long-term impact of treatment decisions. In utilization review, these men and women root their decisions in evidence-based medicine, evaluating all of the presented facts and drawing on their medical knowledge, experience, and know-how to make decisions that stick.

For example, if a physician recommends back surgery, a patient advocate would typically lean towards that resolution. A diligent utilization review nurse, on the other hand, knows that surgery has risks, including Failed Back Surgery Syndrome. If the patient can find relief through other proven avenues of care, then those should be explored first. This focus combines passion and compassion and results in the most efficacious solutions for patients’ long-term health.

2. Attention to Detail

The best utilization review nurses operate with a healthy curiosity and an eye for efficiency. They speak up if any aspect of a claim seems curious. This means questioning a review decision and bringing up issues that were not considered or addressed.

Having all the facts, relying on evidence-based guidelines and remembering that each claim is unique means considering details that may not be obvious upon quick review of a single medical report.

3. Clinical Experience

Utilization review nurses must have clinical experience. Experience gives them the knowledge they need to make informed judgments and to analyze the clinical details. For example, many patients have co-morbity factors that put them at risk or otherwise inform treatment decisions.

Nurses working in utilization review usually have at least two years of clinical experience with backgrounds in a variety of medical specialties including orthopedics, emergency medicine, and family practice. In addition to the required medical knowledge, nurses gain or refine their sense of compassion during clinical experiences.

In addition to passion and compassion, attention to detail and clinical experience, utilization nurses need excellent computer skills or a quick aptitude for learning them. They will be working with powerful software that enables them work efficiently and with the utmost accuracy.

Utilization review nurses form the nucleus of your medical management processes, but a gifted clinician may not always be an asset in your utilization review operation. With the right focus and direction, these men and women will do a great job and serve as a positive presence for your company.

What are your thoughts? Join UR Nation and let us know!

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.

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