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What does a Nurse Reviewer do?

Mary McMahon
Updated Mar 03, 2024
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A nurse reviewer is a nurse who reviews medical records and proposed treatments to determine whether they are covered by insurance. This term is also used to refer to a slightly different nursing career as a nursing reviewer in a hospital who works on quality control issues. Both professions require training and nursing experience to familiarize practitioners with the hospital environment, as well as standards of care in hospital settings. They can require travel, and may come with benefits like health care and retirement accounts.

In the case of a nurse reviewer who works with an insurance company, the nurse reviewer examines patient records to review the treatments provided to the patient. If the treatments seem to conform with standards set by the insurance company, they will be approved for payment. Records of treatments not approved or endorsed by the insurance company will be rejected for payment on the grounds that the treatments provided go beyond the scope of coverage provided by insurance.

Nurse reviewers travel to doctors' offices and hospitals and can also be seen in home care settings, reviewing the treatments provided to patients receiving treatment at home. Their work requires keeping up with current standards of care in medicine, as well as being familiar with the insurance company's policies. A doctor can also work with a nurse reviewer to develop a course of treatment that will be approved by the insurance company. Patients can appeal denials if they feel that a treatment was the only appropriate option.

Quality control with a nurse reviewer involves retaining a nurse or staff of nurses to review patient records in a hospital, clinic, or other treatment facility. They look for signs of quality issues like unusually high rates of complications, risky behavior, and so forth. This information is used to generate policy and practice recommendations with the goal of keeping the standard of care high. Hospitals using nurses for quality control tend to experience better patient outcomes and may be eligible for awards and other recognitions.

For this type of nurse reviewer work, the nurse often works in a fixed setting, sometimes out of an office, reviewing patient records and compiling data. There are training programs available to provide nurses with quality control skills and nurses may use software programs to compile and process data. Experience with patient care is important for people in these jobs, as they have skills and experiences acquired by working directly with patients.

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Mary McMahon
By Mary McMahon

Ever since she began contributing to the site several years ago, Mary has embraced the exciting challenge of being a PracticalAdultInsights researcher and writer. Mary has a liberal arts degree from Goddard College and spends her free time reading, cooking, and exploring the great outdoors.

Discussion Comments

By anon339696 — On Jun 26, 2013

@EdRick: Why would you assume nurses and doctors who are in utilization review don't care for people, but doctors ordering tests, procedures and IP care are all in it to care for patients? That makes no sense.

Utilization Review is not about denying claims - it is helping people by making sure they get the right treatment at the right time at the right place of service. Just because a patient chooses a particular medication or a physician wants a specific procedure or a patient asks to be admitted to a specific facility doesn't mean it is what is best for a patient.

Utilization Review ensures health care dollars are spent according to national standards and that patients receive quality, evidence based care. To suggest otherwise is very misguided and derogatory.

By Viktor13 — On Oct 21, 2011

There is a specialized type of nurse reviewer who works in law offices, reviewing medical malpractice cases. This can be seen by a lot of people as distasteful, but again, the specialized experience of the nurse can be a very valuable thing in making sure only legitimate cases have lawsuits filed.

There are doctors who do this, too. In fact, there is a specialty of law called forensic law where licensed doctors then go through law school and do high-end case review, litigation, and consulting for serious money.

By KLR650 — On Oct 21, 2011

@Azuza - I agree that I want a medical person going over my chart to see if a treatment is covered, rather than a mere clerical worker. The insurance game, whether government or private, can be a sleazy one, but I'm afraid it's here to stay no matter what system we end up with.

At least with a nurse reviewer you have somebody who hopefully has years of experience actually providing the kind of care you are trying to get covered.

By MaPa — On Oct 20, 2011

@EdRick - I get what you're saying, but the truth is that nurses, doctors, Paramedics, and other health care professionals are involved at every stage of the game in health care. Especially as they get older and more experienced, they take management and administrative jobs where their knowledge and experience are very useful.

Patient care can be brutal. Almost everyone burns out at some point. It's great that these jobs exist so that they don't leave the field altogether, but instead stay and use their experience to keep the process running smoothly.

The population is getting older. There's no denying that. More and more of these jobs are going to be opening up. And the nursing work force is pretty old considering the physically demanding work that they do. Many are going to be retiring soon. A lot were already retired and had to go back to work in the recession when they lost retirement savings or their husbands got laid off. These are people who may have 20 years or more in the field and advanced degrees. I say it's good to keep them around, even in an administrative role.

By emtbasic — On Oct 19, 2011

My aunt does this kind of work and she loves it. She has been a nurse for over 20 years. As she got older, the long hours, constantly being on her feet, odd schedules, and incessant demands of the patients and their families really started to take a toll.

This way, she gets to use all of her knowledge and experience, makes a good living, and has her evenings and weekends off. Everybody wins. Some people are just more suited to a regular office job than the demands of patient care.

By PinkLady4 — On Oct 18, 2011

I'm thinking that it is not always an easy job to determine what is covered by insurance. The body is extremely complicated and there are so many different conditions that can come up,that it is hard for an insurance company to write a manual telling whether every possible condition is covered or not.

So the nurse reviewer sometimes has to make an educated guess whether some condition is covered or not. It must be hard.

I kind of think that the nurses who end up in this job have been nurses for a long time, but are just not able, for whatever reason, to do the physical job of a clinical or hospital nurse.

By BoniJ — On Oct 18, 2011

Unfortunately, I think it is necessary to have nurse reviewers checking carefully to see if patients qualify for treatments through their insurance company. Someone has to visit patients to see if their treatments are or will be covered.

If the treatment isn't covered, there are two options. Their doctor may be able to change their treatment to one that would also be effective and is covered by insurance. Or the patient has the right to file an appeal to the insurance company.

I wish we all had full coverage of all medical conditions, but then our insurance premiums would be sky high.

By Azuza — On Oct 17, 2011

@EdRick - I agree with you about the nurse reviewers who work for insurance companies. It does seem pretty sleazy, doesn't it? Part of their job is basically denying people coverage for medical treatments.

However, we should be grateful that any companies actually use nurses for this. I took a class awhile ago about the medical field and we had a unit about insurance companies. The information I heard was disturbing, to say the least.

Some companies require pre-authorization before they will cover a treatment. So basically the doctor or someone at the office has to call the insurance company and ask if they will cover the treatment. If the patients condition doesn't meet certain criteria set out by the insurance company, they won't approve it.

I learned in that class that a lot of people that make those decisions are administrators with no experience in the medical field. They're basically just listening to the symptoms and checking them off a list.

So I'm just grateful that any insurance company (hopefully mine) would hire an actual nurse to review treatments.

By indemnifyme — On Oct 16, 2011

@JaneAir - I have a friend who works in a hospital. From what she tells me, no one likes to hear that they're doing things all wrong or making mistakes. However, people tend to accept quality control as necessary.

I think most people who go into the medical field have the best interests of their patients in mind. Most of them would want to know if they were engaging in unsafe medical practices!

The final outcome has a lot to do with how the hospital chooses to handle things though. If they go around blaming people and people get in trouble, the outcome is less positive. However, if they take the information from the nurse reviewer and use it to educate the staff, then necessary changes can be made.

By JaneAir — On Oct 15, 2011

I think the quality control nurse reviewer job sounds pretty cool. Medical mistakes can happen easily in a hospital. I can also see how it would be easy to get into a routine of making the same mistake over and over again.

A nurse reviewer has specialized knowledge about the medical field. I think this makes them especially qualified to review a hospitals practices and find out where people are making mistakes.

I imagine it might be kind of awkward to report back to a hospital that mistakes are being made though. I suppose it's better than working for an insurance company though!

By sunshined — On Oct 15, 2011

My sister works as a nurse and travels around working as a nurse reviewer. Most of her contacts are in home settings, but she has an office where she spends part of her time as well.

She likes being able to still have contact with people, but does not miss the grueling work of the hospital.

I know many nurses who have put in their time working long hours and shifts in the hospital and get to a point where they are burnt out.

Their expertise and knowledge are helpful when it comes to reviewing claims and treatments. For those on the other end who may be denied claims, I can understand how frustrating it can be.

It seems like the nurse reviewers are in a hard position where they have to follow specific guidelines regardless of the situation.

I am sure there are many times when my sister thinks it was less complicated working in the hospital, but overall really likes the change of pace.

By myharley — On Oct 14, 2011

My cousin worked for many years as a floor nurse and got to the point where it was physically too hard for her to be on her feet that much.

She enjoyed her job and taking care of her patients, but needed to find a different type of job.

She had the opportunity to apply for a nurse reviewer job and thought this would be a good fit for her. She would still be involved in the nursing field but would be doing more administrative than practical work.

All the years she spent working in the hospital were a big benefit for her. She has been working as a nurse reviewer for a few years now and it has been an interesting transition for her.

No doubt there have been times when she has been frustrated, but this is no different from any other position. She just does her job to the best of her ability and is thankful to still have a job where she can utilize her training and skills.

By robbie21 — On Oct 14, 2011

@EdRick - This is one of those fields that gets a bad rap that is not necessarily deserved. Absolutely, it is possible for insurance companies to abuse this position. They could put undue pressure on the nurse reviewer to find reasons to reject claims.

But there is also a positive side. Insurance companies want to pay for only the most effective treatments. And remember, insurance companies use the premiums paid by all the members to pay for treatments when one member gets sick, so really, they are using *your* money. Don't you want your money used in the most effective way possible?

So a nurse reviewer would make sure that the patient was receiving the right standard of care. Registered nurse jobs are definitely tough, but where would we be without them? Let's not throw stones at hardworking people.

By EdRick — On Oct 14, 2011

I don't understand how anyone could take a utilization review nurse job. Don't nurses and doctors go into the field to help people? How does refusing treatment help people?

I'm sure that it's nice to get to work regular hours, no night shifts, and I know some nurses burn out on patient contact. I know it's physically very difficult work. But really - to go from directly caring for people, to having it be your job to find reasons to deny claims?

Mary McMahon

Mary McMahon

Ever since she began contributing to the site several years ago, Mary has embraced the exciting challenge of being a...

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