The process of utilization review (commonly referred to as UR) is usually a component of a utilization management (referred to as UM) program within a health insurance company, healthcare system, or utilization management organization. Utilization review physician jobs are often focused on reviewing requests for healthcare services in order to determine whether treatment is appropriate and/or medically necessary.
Utilization review is a popular consideration for physicians looking for nonclinical work. But many hesitate at the thought of a utilization review physician job. Some are concerned that it will be boring or tedious. Others feel that utilization review physician jobs are somehow “going to the dark side.” Others cringe at the thought of having adversarial peer-to-peer calls with other physicians.
I’ve worked in utilization review for close to 5 years and really enjoy it. For doctors on the fence about whether to pursue a position in utilization review, here are 10 reasons why I love it.
1. Helping to ensure that health care is appropriate
Physician utilization review work involves taking a deep look at a request for authorization of payment for a healthcare service. The physician reviews the relevant medical documentation in the context of clinical evidence and the payor’s policies to determine whether the service will be covered under the insurance policy.
Many requests are not medically necessary and some are not even medically appropriate – based on literature, clinical practice guidelines, and accepted standards of care. The physician review process ensures that patients receive care that is evidence-based.
Cost savings is a natural result of the review process. Utilization management programs are a key reason that healthcare payors can remain in business.
2. Playing a role in patient care without directly treating the patient
I enjoy non-clinical work. But I also value being involved in helping patients, treating diseases, and improving health. Utilization review allows me to do this. I don’t make treatment decisions or write orders as part of my utilization review work, but my work has a positive impact on the care that ends up being provided.
3. I get to focus on a single task at a time
In clinical roles, we’re often pulled in several directions. We’re constantly interrupted and asked to switch our thoughts to a different patient or problem. We end up trying to multitask. This can be a component of why medical errors take place.
For the most part, this doesn’t happen in utilization review physician jobs. I have a queue of cases that need to be reviewed, and I work through them consecutively.
I do get some unscheduled calls, urgent emails, and other interruptions. However, this sort of thing happens far less frequently than in clinical work.
4. Medical documentation is entertaining
Utilization review is anything but boring. Many physicians have a sense of humor that comes through in their documentation. Patients say wacky things that get written in their charts. Humorous and astonishing medical situations happen. And I get to read all this stuff as I do my reviews.
5. Each review is like a mini-investigation
Reviewing a request or hospitalization requires delving into clinical documentation and pulling out components that demonstrate a service’s necessity. The review needs to be detailed, as sometimes a single piece of clinical data can alter the determination. It also needs to be impartial, taking peer-reviewed literature and company policy into consideration.
A review may only take a few minutes of my time, but it includes a distinct process and steps that turn it into a structured investigation.
6. Staying up to date in a field that I’m passionate about
Utilization review requires reading and understanding best practice guidelines, clinical trial results, and other publications. Medical practice is changing all the time. The success of a physician reviewer depends on the ability to identify the most current evidence and apply it in the context of a request or a hospitalization.
Many utilization review physicians are also involved in developing and revising their organization’s coverage policies, which is yet another opportunity to keep updated in the field.
7. The ability to take an unbiased look at a clinical situation
Sometimes my medical decisions in a direct care setting are influenced by, well, the direct care setting. For example:
- I’ve been guilty of ordering tests and writing scripts when patients are demanding.
- Knowing that I have 4 or 5 patients backed up in the waiting room has made me rush into making treatment decisions.
- When there’s an obvious clinical finding, I’ve ignored a more subtle – yet important – finding as I try to take action quickly.
Utilization review allows a physician to review a clinical scenario without these extraneous factors. I value being able to take an unbiased approach to apply the science of medicine.
8. Job location and schedule flexibility
This one is huge for many physicians considering utilization management jobs. It varies greatly depending on the employer and the exact responsibilities of the position; however, for the most part, utilization review jobs have more schedule flexibility than clinical jobs and many other types of non-clinical jobs.
Many utilization review physician jobs are remote positions (such as many with Aetna and Humana), though there are also some that require in-office work. But even office-based work beats hospital- or clinic-based work for some doctors!
9. A perfect mix of autonomy and collaboration
I spend a large part of my day by myself, in silence, working on my own. It’s awesome.
There is a significant amount of collaboration, as well. Most organizations with a utilization management program have a whole team of physician reviewers. They all need to be on the same page. So there are meetings, committees, curb-sides, and discussions.
All in all, it’s a good mix of autonomy and collaboration.
10. Better writing and communication skills
As a physician reviewer, my notes need to be concise and accurate. They need to be clear and unambiguous. Utilization review has made me a better writer.
Do you need to love writing to be a utilization review physician? Nope! Reason #10 could be any of numerous other skills for you. A utilization review job is far from approvals and denials. You can improve many skills as a physician, reach professional goals, and set yourself up for career advancement.
Do any of these resonate with you? If so, consider a career in utilization management!