The Nurse's Complete Guide to Utilization Management

Leave the bedside. Keep the nursing.

There is a nursing career where your clinical judgment matters more than your stamina, where the schedule is human, and where the commute is a hallway. Utilization management nurses review authorization requests against evidence-based criteria and help patients get the right care, in the right setting, on time. And both RNs and LVNs can do it.

Written by a working UM nurse with more than ten years in the field who helped build a health plan from the ground up, this book hands you the entire map in plain English, starting from zero. It was born in a hospital bed: during a period of illness, the author's own nurses kept asking the same questions. What kind of nursing do you do? How do you do it? How do I get into it? This book is the complete answer, written for every nurse who wants to learn more and leave bedside care.

Inside, you will learn how to:

• Read CPT, HCPCS, and ICD-10 codes the way reviewers do
• Process an authorization from fax to decision and hit every turnaround time (TAT)
• Handle contracted vs. non-contracted providers, including when to redirect members back into network
• Find real criteria for free: CMS NCDs and LCDs, plus the public medical policy libraries of major payers
• Understand the DOFR, eligibility, benefits, and levels of care
• Approve what meets criteria, pend what is missing, and refer denials to the medical director the right way
• Navigate tertiary facilities, Centers of Excellence, and transplant cases
• Protect yourself with HIPAA-smart remote work habits
• Interview with confidence, whether you are an RN or an LVN

Then practice with 16 complete sample case reviews. Each case gives you the line of business, the codes, realistic clinicals, the exact source where the guideline lives, and a finished review note in the format working reviewers actually write. Sleep studies, CPAP, spinal injections, power wheelchairs, MRIs, joint replacements, home health, SNF stays, hyperbaric oxygen, bariatric surgery, cardiac devices, transplants, and more.

You will also get a full mock interview to rehearse out loud, quick-reference code appendices, a sample TAT grid and prior authorization grid, and a glossary that lets you talk like you have been in the field for years.

If you are burned out, injured, raising kids, or simply done with twelve-hour shifts on concrete floors, this is your proof that there is another room in the house of nursing. Your license is the key. This book is the door.

Camara Starks, LVN, is the founder of ClearlyAuthReady, a companion practice platform where readers can run mock authorization reviews built on the exact skills in this book.