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.