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An In-Depth Look at Utilization Management Nursing

What Does Utilization Management Nursing Entail?

While a typical registered nurse's primary responsibility is to the patient, a utilization management nurse must answer not only to the patient, but also to the physician, the hospital, the employer, and the insurer. Utilization management nurses, sometimes called case managers, merge medical know-how with the financial needs of insurers and care providers to approve or seek payment for medical procedures, treatments, devices, or hospital stays. They may work for insurance companies, hospitals, social services, or state and local health departments.

Education & Training Required to Work in Utilization Management Nursing

Only registered nurses, who have earned certification through a bachelor of science in nursing (generally preferred), associate's degree in nursing, or a nursing diploma, can work in the advanced specialty of utilization management. Additionally, a certain level of clinical nursing experience is often required. Although not required by every employer, you may earn advanced certification through either the Commission for Case Manager Certification or the American Nurses Association. Some experience or training in risk management might also be helpful.

Typical Characteristics Required to Work in Utilization Management Nursing

A utilization management nurse may review 20-40 cases per day and must provide responses to claims within a day or two. The numerous ethical dilemmas that arise in which your commitment to treating patients conflicts with the demands of insurer payment rules can be stressful. You'll need excellent organizational skills, the ability to communicate effectively, a willingness to handle stress and make quick decisions, and, of course, strong computer skills.

High Demand for Utilization Management Nurses

With health care reform and the mandate to update health information technology, the need for nurses who are fluent in medical, administrative, and insurance terminology is expected to increase rapidly. Right now, the Bureau of Labor Statistics projects that registered nurse jobs will add the greatest number of new jobs between 2008 and 2018 of any job in the U.S. economy.

While the BLS does not specifically track utilization management, research shows that these specialized nurses generally earn higher salaries than the average registered clinical nurse, who earned a median annual wage of $62,450 in May 2008. Other benefits include a predictable 8-5 workday, weekends and holidays off, and the frequent ability to travel or telecommute, making this profession a desirable one.

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