Utilization Review Nurse Salary Guide

Utilization review nurses generally work behind the scenes but fulfill a vital role. They’re one of the primary ways healthcare facilities and insurance companies control costs for patients. The job often involves making difficult decisions as UR nurses strive to strike the ideal balance between providing high-quality patient care and cost-efficient healthcare services. Nurses may work on the medical side or the insurance side of utilization review. Work setting along with other factors like education and experience, impact the salary of utilization review RNs.

Utilization review nurses are registered nurses who specialize in combining their clinical and administrative experience to effectively monitor the quality of patient care while helping control healthcare costs. UR RNs employed by hospitals determine whether patients are eligible for insurance coverage on specific treatments and help patients compare covered treatments and medications to ensure they don’t pay out-of-pocket for hospital/doctor visits and treatments. Alternately, UR RNs employed by insurance companies focus on pre-certifying patients for necessary procedures and hospitalizations and determining whether they meet the standards for insurance reimbursement.

The education requirements to enter UR nursing include a minimum of an Associate Degree in Nursing, but most employers prefer a Bachelor of Science in Nursing. Nursing programs must be accredited by the Commission on Collegiate Nursing Education (CCNE) or the Accreditation Commission for Education in Nursing (ACEN) and all graduates must pass the NCLEX-RN to obtain RN licensure.

Most employers prefer hiring UR nurses who have a BSN, extensive hands-on nursing experience, and an administrative background, so education and experience are going to play a big role in how a utilization review RN’s salary is based. Additional skills, industry, and geography can also factor into base salaries. 

UR nursing applicants need a solid history of nursing practice to get hired and earn a good base salary. Employers typically want to see three to five years of clinical practice and some prefer UR nurses with at least two of those years in acute care. Some employers may also prefer applicants with experience in managed care. The exact experience a facility prefers can vary and it will likely be a factor in how they base their UR nurse salaries.

Experienced nurses are uniquely suited to entering utilization review because they’ve gained extensive knowledge of patient care and hospital procedures along with a wide array of skills in performing various medical treatments. The additional knowledge and skills they’ve acquired and honed over the years, improve their clinical judgment. Their improved judgment helps them make better decisions that promote patient health while keeping resources in check.

The base salary for a utilization review RN can also vary depending on the industry that employs them. The insurance industry tends to have higher base salaries than the healthcare industry. Geography can also play a role. Many states in the northeast and on the West Coast, especially California, pay higher salaries than in Middle America. However, these higher salaries are typically based on the fact that these areas have a higher cost of living.

Certifications can be a powerful tool for utilization nurses to show employers they know their stuff and earn them a bump in salary. Utilization review RNs can increase their salary by earning professional certifications in areas like case management, patient care coordination, and healthcare planning. 

Health Care Quality and Management Certification earned through the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP) is available to registered nurses. It demonstrates that an RN has the knowledge and tools necessary to ensure patient safety, reduce medical errors, avoid potentially harmful delays in care, and eliminate waste and unnecessary services.

RNs must provide documentation of active involvement in Health Care Quality and have completed at least 208 hours in utilization management, quality improvement, case/disease management, risk management, transitions of care, or managed healthcare systems to sit for the exam. They must also complete the ABQAURP Core Body of Knowledge online course or 25-plus hours of ABQAURP-approved continuing education. The ABQAURP also offers sub-specialty certifications in case management, patient safety/risk management, and managed care.

Because there’s considerable overlap between case management and utilization review, earning Nursing Case Management board certification through the American Nurses Credentialing Center also can be a good credential for increasing a UR nurse’s salary. Exam eligibility includes practicing full-time as an RN for two years and completing at least 2,000 hours of clinical practice and 30 hours of continuing education in nursing case management in the last three years.

Take a look at Vivian's Utilization Review Nurse Career Guide for more information, including required education, responsibilities, pros and cons and more.