What Does a Utilization Review Nurse Do?

A utilization review nurse plays a critical role in healthcare settings, including substance abuse and mental health treatment spaces. They act as a patient advocate, deciding what is going to happen with a person’s care and making a case for why it is necessary. But, what does a utilization review nurse do on a typical day? Providing a breadth of services, such as utilization review, for behavioral health providers, Hansei Solutions is here to help.

Key Points:su

• A utilization review nurses role is to make sure that people receive appropriate, cost-effective treatment. 
• Hansei offers ethical utilization review services exclusive to the behavioral health field. 

What Does a Utilization Review Nurse Do?

What does a utilization review nurse do? The main goal of a utilization review nurse is to evaluate the necessity of healthcare services and ensure that people receive adequate care for their health condition or concern while balancing the need to control costs. Some of your main duties in the role will include:

• Reviewing medical records and assessing treatment plans. As a utilization review nurse, you will look at patient records to support the necessity of a service. Throughout the course of treatment, continued review is necessary. You’ll oversee the response to a person’s current treatment and determine whether a change in their level of care is suitable (e.g., moving from inpatient to outpatient addiction treatment) yet. 
• Medical necessity charting. Throughout the course of treatment, utilization review nurses must document a client’s need for care thoroughly. Attention to detail is necessary. The more of a case you can make for the person’s need for care, the less likely they are to be denied treatment. 
• Working with insurance companies and claims. One of the most challenging roles of a utilization review nurse is often navigating insurance-related issues. While a big part of the role is preventing denied claims from happening in the first place, you may have to review denied claims and make a statement regarding medical necessity. 
• Collaborating with other providers to coordinate services. To promote the most effective use of healthcare services (e.g., encouraging lower levels of care when appropriate, assisting in discharge planning), you will work closely with other providers involved in a patient’s care. The goal is to ensure that everyone’s on the same page, ideally, and that any transitions are as seamless as possible for the patient. 

If you’re looking for a utilization review nurse, it’s integral to find the right fit. You need utilization review professionals who can strike a delicate balance between cost management and helping individuals in need of healthcare services get the best possible care: the kind that will set them up for long-term success. That’s where Hansei Solutions comes in. 

Utilization Review With Hansei Solutions

Utilization Review With Hansei Solutions prioritizes your and your clients’ best interests. Since we focus exclusively on behavioral health, we employ specialists who are versed in utilization review for mental health and addiction treatment. Our experts are here to coordinate care, provide case management, reduce risks, and increase access to services in the most cost-effective way possible. 

Medical Credentialing With Hansei Solutions

Utilization review nurses must maintain their licensure. Medical Credentialing With Hansei Solutions can help you ensure that your utilization review nurses (and other providers) remain up to date with licensing, credentials, and regulations. We have a strong understanding of requirements in different states and jurisdictions, allowing us to streamline the process for our clients. 

Claim Denial Management With Hansei Solutions

Another thing we can help with? Claim Denial Management With Hansei Solutions helps behavioral health providers, treatment centers, clinics, and groups fight denied claims. We’ll fight to make sure the people in your care get the help they need.

Onboarding With Hansei Solutions

Ready to get started? Learn more about Onboarding With Hansei Solutions today. Our experts are here to handle everything from billing to supplying the data you need to make critical business decisions and increase revenue, with reports available 24/7/365. 

Contact Hansei Solutions for Utilization Review in Addiction and Mental Health Treatment 

Since 2016, Hansei has been a premier revenue cycle management partner for behavioral health providers. We help treatment centers and professionals get paid faster, stay compliant, and make ethical, growth-oriented business decisions. Contact Hansei Solutions for addiction and mental health utilization review services today at 888-574-4379. Or, book a demo now through our website.

FAQs 

How do you become a utilization review nurse?

To become a utilization review nurse, you must be a registered nurse (RN). Ideally, with a Bachelor of Science in Nursing (BSN). About 2-3 years of experience (or more) is necessary for learning about the treatment and procedural options available for the cases you’ll work on. Even though training isn’t always required, you can obtain a Case Management Nurse – Board Certified (CMGT-BC) or Health Care Quality and Management (HCQM) certification to increase your chances of employment. Each employer will have their own unique requirements for utilization review nurses, which is something to keep in mind if you’re considering the career path. 

Can utilization review nurses work remotely?

Yes. Many utilization review nurses now work remotely or in hybrid settings (a combination of in-person and at-home work). It is a great option for people looking for remote work who have the required skills. 

What skills do utilization review nurses need to have?

Again, utilization review nurses need to be detail-oriented. They must also know about treatment options and procedures, which they’ll generally gain from prior experience. Other necessary skills include, but aren’t necessarily limited to:

• Communication and interpersonal skills. A good utilization review nurse is diplomatic and able to communicate with other healthcare providers, insurance companies, and patients. It’s important that you’re able to negotiate and advocate for patients when needed. 
• Technology proficiency. You will need to be familiar with utilization software and must be able to navigate electronic medical records. 
• Decision-making. You will need to make decisions, sometimes in high-pressure situations. 

Utilization review nurses fill a very important role. Even though there can be hard moments, it is a rewarding career, and it is less physically demanding than bedside nursing. With an increased need for cost-efficient healthcare services, there is a high demand for utilization review professionals.

Resources  

https://www.nursingworld.org/content-hub/resources/nursing-resources/utilization-management-nurse/