Who Does Utilization Review?
UR is frequently, but not always, done by nurses.
If they agree on a course of treatment, the treatment can proceed.
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Sometimes, the hospital UR nurse is also the discharge planner.
When UR and discharge planning are combined into one job, it’s known ascase management.
The hospital UR nurse communicates with the UR nurse at Sams health insurance company.
The hospital UR nurse follows Sams progress every day or two.
Department of Labor’s Employee Benefits Security Administrationif the health plan is self-insured.
Utilization review specialists are often nurses.
They work for health insurance companies, hospitals, and various other medical providers.
This helps to expedite prior authorization from health plans and ensure that patients' claims are covered.
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Indeed.What Is a Utilization Review and Who Performs Them?Aug.
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Healthcare IT News.Reinventing utilization management.
RevCycle Intelligence.Hospital Utilization Management Can Reduce Denials, Improve Care.
HealthCare.gov.How to appeal an insurance company decision.
National Association of Insurance Commissioners.Utilization Review and Benefit Determination Model Act.
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MCG.com.The Utilization Review Process and the Origins of Medical Necessity.
