Recruiter's Glossary

Examples: Medicare • Capitation • HCPCS

Utilization Review

Term from Health Insurance industry explained for recruiters

Utilization Review is a process used in healthcare insurance to evaluate whether medical treatments, procedures, or services are necessary and appropriate for patients. It helps insurance companies and healthcare organizations manage costs while ensuring patients receive proper care. Think of it as a quality check system that makes sure healthcare services aren't overused or underused. Similar terms include "Medical Necessity Review," "Care Management Review," or "Treatment Authorization." People who work in Utilization Review help decide if requested medical treatments should be approved for insurance coverage.

Examples in Resumes

Performed Utilization Review for 200+ cases monthly, ensuring appropriate healthcare service delivery

Led team of 5 nurses conducting Utilization Reviews and UR assessments

Reduced healthcare costs by 15% through effective Utilization Review Management practices

Typical job title: "Utilization Review Nurses"

Also try searching for:

Utilization Review Coordinator UR Nurse Care Manager Medical Review Specialist Clinical Review Nurse Utilization Management Nurse Healthcare Review Specialist

Where to Find Utilization Review Nurses

Professional Organizations

Job Boards

Professional Networks

Example Interview Questions

Senior Level Questions

Q: How would you handle a complex case where a physician strongly disagrees with a denial of service?

Expected Answer: Should demonstrate expertise in conflict resolution, thorough understanding of medical necessity criteria, and ability to communicate effectively with healthcare providers while maintaining professional relationships and following insurance protocols.

Q: How would you implement process improvements in a Utilization Review department?

Expected Answer: Should discuss experience with workflow optimization, team leadership, measuring outcomes, and balancing quality patient care with cost management while maintaining regulatory compliance.

Mid Level Questions

Q: What factors do you consider when reviewing a request for an urgent procedure?

Expected Answer: Should explain consideration of medical necessity criteria, patient history, current condition, alternative treatments, and understanding of urgent vs. non-urgent care guidelines.

Q: How do you stay current with insurance policy changes and medical guidelines?

Expected Answer: Should mention regular review of policy updates, participation in continuing education, professional memberships, and following healthcare industry news and regulations.

Junior Level Questions

Q: What is the basic process of conducting a utilization review?

Expected Answer: Should describe steps of reviewing medical documentation, applying criteria, consulting guidelines, and making determinations based on medical necessity and policy requirements.

Q: How do you ensure patient confidentiality in your review process?

Expected Answer: Should demonstrate understanding of HIPAA regulations, proper handling of medical records, and basic privacy protocols in healthcare settings.