Overview
Utilization review nurses assess clinical necessity for admissions, continued stays and procedures and coordinate with care teams and payers to align care with guidelines and coverage criteria.
Clinical Review Activities
They review medical records, apply utilization criteria, recommend alternatives and support appeals and case management for complex patients.
Impact on Care and Cost
By ensuring appropriate resource use, utilization nurses help reduce unnecessary stays, optimize transitions and support value based care objectives.
Qualifications and Practice
Typically RNs with case management or utilization experience, they require strong clinical judgment, documentation skills and knowledge of payer policies.