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What is the process of utilization review?

A utilization review is a process in which a patient's care plan undergoes evaluation, typically for inpatient services on a case-by-case basis. The review determines the medical necessity of procedures and might make recommendations for alternative care or treatment.

What does a utilization review do?

Utilization review is a method used to match the patient's clinical picture and care interventions to evidence-based criteria such as MCG care guidelines. This criteria helps to guide the utilization review nurse in determining the appropriate care setting for all levels of services across the arc of patient care.

What are examples of utilization review?

Other examples of utilization reviews might include determining whether or not a patient should be transferred to a specialty trauma ICU at a regional center or getting insurance approval for an extended hospital stay that goes beyond the typical guidelines.

What are the responsibilities of a utilization review nurse?

Utilization review nurses perform frequent case reviews, check medical records, speak with patients and care providers regarding treatment, and respond to the plan of care. They also make recommendations regarding the appropriateness of care for identified diagnoses based on the research results for those conditions.

What is another name for utilization review?

Utilization review is synonymous with, or a part of, utilization management (depending on how the terms are used).

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