Utilization Review RN: Education Requirements and Career Info

A utilization review registered nurse (RN) finds the most effective use of a patient's insurance coverage and balances it with doctor's recommendations, hospital care costs and other medical considerations. Many hospitals and medical care facilities are finding an increasing need for a specialist in this field to ensure that a patient gets the best possible care within the dictates of financial and insurance guidelines.

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Education Requirements for a Utilization Review RN

Bachelor of Science in Nursing

A utilization review registered nurse must first fulfill the education and licensing requirements of a RN, including a degree in nursing and successfully passing the National Council Licensure Examination for registered nurses (NCLEX-RN). Though nursing degree programs are available as both associate's and bachelor's degrees, employers may prefer utilization review nurses to have at least a bachelor's degree. Bachelor of Science in Nursing programs typically include classes in anatomy, microbiology, psychology, chemistry, pharmacology and medical terminology.

Medical Case Management Certificate

After gaining experience as a registered nurse, prospective utilization review nurses may enroll in a certificate program in medical case management or health care risk management to learn more about the utilization review process. These programs typically require applicants to already be an RN or another medical professional. These programs typically include coursework in patient safety, clinical ethics, risk management, medical insurance and health care standards.

Career Information

Utilization review nurses review the risks and liabilities for hospital and clinic patients. They review potential medical procedures and serve as a liaison between patients, care providers and insurance companies. Utilization review registered nurses may work in a variety of settings, including hospitals and other medical care facilities, as well as insurance companies and nursing homes.

A utilization review RN should have a firm understanding of insurance procedures and how they work in conjunction with hospital or facility policies. A survey of various job postings for this position shows that many facilities hiring utilization review RNs prefer experience in a like facility, such as acute care, home health care and emergency care. Expertise in state, federal and third party payment regulations may also be beneficial, as well as good communication and computer skills.


In December 2013, Payscale.com showed the salary for utilization review RNs ranged from $49,510 to $86,361 annually. Nursing homes, acute care hospitals and insurance carriers typically offered the potential for the highest pay. California and New York were the states offering the highest pay on the upper end of the salary ranges.

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Source: Bureau of Labor Statistics