Utilization Management (UM) is the process of ensuring that health care services are performed in a cost-efficient and guideline-compliant nature. Utilization Management Nurses play an important role in containing healthcare costs by reviewing rendered services against standardized guidelines to ensure appropriate utilization of resources.
There are several Utilization Management roles that vary based on the timing in the usage cycle.
Pre-Service
- Prior Authorization
- Review requests from providers or members for approval of non-covered procedures, medications, or services prior to their delivery
- Denials & Appeals
- Secondary review of services that have been reviewed and denied.
During Service
- Concurrent Review
Post-Service
- Denials & Appeals
- Mentioned before under Pre-Service, Denials & Appeals can also occur Post-Service.
- Review appeals from providers or members for procedures, medications, or services that were denied coverage after their delivery
To dive a bit deeper, I conducted a poll of 26 Utilization Management Nurses and found some interesting stats:
- 72% of UM Nurses reported salaries between $60,000-$80,000
- Several nurses mentioned that generalized nursing knowledge, as opposed to specialized knowledge, served them best in their transitions to UM nursing. This is because many UM positions involved a wide variety of diseases and services. Interestingly, the most common nursing backgrounds prior to UM roles were in Medical-Surgical, Case Management, and ICU
- 44% of UM nurses had 11+ years of nursing experience
- 88% of UM nurses reported that Fully Remote/Work-From-Home options exist for these roles!
Thank you to all the nurses who responded!
Are you interested in becoming a Utilization Management Nurse?
Visit my UM Job Page to explore options now!
Remote Nurse Spotlight:
We have a robust population of Utilization Management Nurses on the Remote Nursing Jobs Facebook group. Heather Willems is one of them and she has graciously agreed to give us an inside look into the life of a *real life* Remote Utilization Management Nurse! Thanks Heather!
About me:
I’m Heather Willems and I have been a Registered Nurse for over 21 years. I grew up in Georgia where I graduated from Emory University with my BSN. 
I moved to Wisconsin over 11 years ago after meeting my husband who grew up here. We have two little boys, 7 and 9. I started my career in women’s health and spent many years in PACU at a large hospital in Atlanta. After moving to Wisconsin, I was lucky to work at an office for an independent pulmonologist for five years. After starting a family, this was a great schedule with no nights, call, or weekends. Six years ago, we wanted to be closer to my husband’s family, and so we moved to De Pere, Wisconsin, just outside of Green Bay. This is where I began my first position as a Utilization Management nurse with a large insurance company.
Why I left bedside nursing:
I’m sure most of you can relate that you went into nursing because you care. You are a nurturer and a caretaker. You want to help others feel better.
As a young nurse in PACU, I gave everything to my job. I was single and living in the big city with no children. I spent so many hours on my feet without a break, without a bite to eat, or a chance to go to the bathroom.
The big shift for my desire for a remote position was after having our second son. I learned that just because you work at home with this role does not mean you do not need daycare! However, at least the flexibility was there to no longer make a commute or pack lunches and snacks on the go.
If the children were sick and couldn’t go to daycare, this was not an issue to call in sick versus the days in the hospital or clinic when I felt so guilty any time I needed to call in. I also now had my in laws close by that could help as well with the children if home sick. Additionally, if I’m feeling run down or maybe have a cold or cough, I am still able to work and not get anyone else sick.
Day to day role as a UM Nurse:
I have worked as a UM nurse for a large insurance company for six years. My roles have varied somewhat in what I have reviewed and how the job is performed. Hopefully this will give you more insight on what this role entails so that you can educate yourself and know if this is a fit. If you do apply and you get interviewed, this can also help you know what your employer may be looking for as well as questions you may want to ask the employer.
You will need to have access to high speed internet for most companies I’ve seen.
Do not worry about buying equipment! They will supply everything once hired. The only thing you need to worry about is a private work space, desk, and chair.
Going from the bedside to this role brings about a big change and its own set of responsibilities and challenges.
The role is described as using clinical nursing skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations.
In the insurance world, you will be trained, depending on your role, for commercial or Medicare, and the roles vary from prior authorization to a retro role, which is reviewing for meeting criteria after services have been rendered.
I’ve reviewed anything from DME to inpatient and outpatient stays, labs, and therapy claims.
You are using your clinical judgment to look over the medical records given and then look at the policies to see if meets criteria or not.
As a nurse, you know you have the clinical background. What the employers are looking for is that you are able to move throughout multiple systems, again that they train you on, to see if criteria is met per their policies.
This requires learning a lot of new systems in which the claims and records are entered into, and they need to know you can move throughout these quickly and complete an expected production while maintaining quality.
If criteria is not met, reviews then go to a medical director for determination.
If you are working in some of these roles, like my first one, you will be on the phones and I did not realize this when I first started! This included calling members if services were not covered or calling provider’s offices to offer a peer to if a review was not approved by a medical director.
I personally got a lot of anxiety making these calls, and if that sounds like something you would not want to do, I would highly encourage you to research the UM role you’re applying to and if you interview, ask if the role involves phone calls or not!
I want to emphasize the realities of my day to day expectations as a UM Review nurse with an insurance company.
Other UM nurses may have a completely different experience outside of insurance, but I want you all to know as much as possible before leaving the bedside and just applying to any role you see.
Just because you are working from home does not mean you will be able to do your work with small children at home! I’ve seen this question asked many times so I wanted to make sure I included that here.
This is certainly role-dependent, but for most UM positions I’m familiar with, there are often times phones involved and high production requirements.
You will still need to pay for a sitter or daycare for most roles.
You will have a daily or weekly production requirement to meet. Most employers, including mine, are watching more closely what you are doing with your time, some down to the minute to see if you are using your keyboard or mouse. You do get scheduled time for lunch and breaks, but you will not be able to go about and do what you want and when you want during the day in this role. You will be busy to get your work completed and you will be expected to be at your desk at all times other than your breaks.
Your reviews will be audited for quality to make sure you are making the right determinations as well.
How did I get started and where am I headed?
I had no experience prior to this role. I honestly kept applying and applying until I landed an interview! I know it can be discouraging, but just keep trying! That’s what many of us that landed a role had to do.
I have a BSN, but LPNs have worked in these roles as well.
These employers receive so many applications for these roles, and it’s hard for your resume to sometimes even be seen!
This is where networking can come in handy if you can find someone on the inside to help connect you to someone as well.
I tend to do well with interviews and happy to help anyone if they need some tips for interviews and questions.
Even if this doesn’t sound like your ideal role, the good news is, once hired, this opens the door for other possibilities to make yourself more marketable in the future.
I’m currently looking into possibly obtaining my coding certification and also looking into other roles with fraud and waste abuse investigations and quality assurance within the organization now.
Health and wellness is my passion as well as educating others on consuming and using safer and cleaner nutritional and personal products. I’ve found the online space and the power of social media to be an effective vehicle to help nurses earn additional income while making an impact serving others. You can find out more here if interested!