Utilization Review
Utilization Review is a process in healthcare where professionals evaluate whether medical treatments and services are necessary, appropriate, and cost-effective for patients. It's like being a quality checker who makes sure patients get the right care without unnecessary procedures or extended hospital stays. These reviews help insurance companies and healthcare facilities manage resources while ensuring patients receive proper care. Similar terms include "Care Management" or "Medical Necessity Review." This role bridges the gap between healthcare providers and insurance companies.
Examples in Resumes
Conducted Utilization Review for 200+ patient cases monthly, ensuring appropriate healthcare service delivery
Led Utilization Review team to achieve 95% accuracy in medical necessity determinations
Performed concurrent Utilization Review and UR assessments for inpatient hospital stays
Managed Utilization Management program for a 300-bed hospital
Typical job title: "Utilization Review Nurses"
Also try searching for:
Where to Find Utilization Review Nurses
Professional Organizations
Job Boards
Professional Networks
Example Interview Questions
Senior Level Questions
Q: How would you handle a disagreement between a physician and insurance company regarding treatment approval?
Expected Answer: A senior reviewer should explain their process of gathering clinical evidence, facilitating communication between parties, using medical criteria to support decisions, and following appeal procedures when necessary.
Q: Describe how you would implement changes to improve the utilization review process.
Expected Answer: Should discuss experience in developing new protocols, training staff, measuring outcomes, and collaborating with different departments to streamline processes while maintaining quality care standards.
Mid Level Questions
Q: What criteria do you use to determine if a hospital stay is medically necessary?
Expected Answer: Should explain use of evidence-based guidelines, assessment of patient condition, consideration of treatment alternatives, and understanding of insurance criteria for medical necessity.
Q: How do you manage concurrent review of multiple cases?
Expected Answer: Should describe prioritization methods, time management skills, use of review tools, and ability to maintain accuracy while handling multiple cases.
Junior Level Questions
Q: What is the difference between prospective, concurrent, and retrospective review?
Expected Answer: Should explain that prospective review happens before treatment, concurrent during treatment, and retrospective after treatment, with basic understanding of each type's purpose.
Q: How do you ensure patient confidentiality in your review process?
Expected Answer: Should demonstrate understanding of HIPAA regulations, proper handling of patient information, and basic privacy protection procedures.
Experience Level Indicators
Junior (0-2 years)
- Basic understanding of medical terminology
- Knowledge of insurance guidelines
- Documentation review
- Basic computer skills for healthcare systems
Mid (2-5 years)
- Independent case review management
- Insurance criteria application
- Communication with healthcare providers
- Understanding of multiple insurance plans
Senior (5+ years)
- Program development and improvement
- Team leadership
- Complex case management
- Policy development and implementation
Red Flags to Watch For
- Lack of clinical background or healthcare experience
- Poor understanding of insurance guidelines and medical necessity criteria
- Limited knowledge of healthcare regulations and HIPAA
- Weak communication skills or inability to handle conflict
Related Terms
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