For RNs and LVNs
Leave the bedside. Keep the nursing.
A practical introduction to utilization management for RNs, LVNs, and LPNs. Learn the language of prior authorization, review workflows, and documentation, then explore nursing work beyond the bedside.
The Nurse's Complete Guide to Utilization Management: Prior Authorizations, Criteria, Denials, DOFRs, and the Remote Nursing Career Nobody Told You About by Mr. Camara Starks, LVN
Get the Book on AmazonAvailable now in hardcover and paperback.
If you've ever cried in your car before a shift, this book was written for you.
Not because you're a bad nurse. Because you're a human one. Twelve-hour shifts on concrete floors were never the only way to use your license, and nobody told you that.
Utilization management (UM) is a set of processes used to review the appropriateness of health care services using clinical information, evidence-based criteria, and applicable coverage policies. A review may happen before care, during treatment, or after a service. Nurses can help gather information, document findings, and communicate next steps within their authorized role.
UM offers chart-based work. Positions may be remote, hybrid, or on-site, depending on the employer.
Schedules vary by employer and role. Review the posting for business hours, weekends, and on-call expectations.
Explore roles for RNs and LVNs/LPNs. Duties and decision authority depend on licensure, applicable requirements, and employer policy.
Prior authorization is one form of prospective review. For services that require it, the reviewer examines the request and supporting records before the service is provided. Not every service requires prior authorization.
Concurrent review takes place while care is underway. It can involve reviewing updated records, the current setting, and continued service needs as the care team plans next steps.
Retrospective review examines services already delivered. It uses the available record and applicable policies to evaluate the care under review.
The terms overlap and organizations may use them differently. Utilization review usually describes reviewing a particular request, service, or stay. Utilization management is often the broader program that organizes those reviews, its policies, and related processes. Learn how your employer defines both terms.
The work can include reading medical records, locating the applicable policy, identifying missing documentation, recording findings, and communicating with providers and other reviewers. Careful reading, clear writing, and consistent follow-through are useful skills to develop.
Clinical criteria, coverage benefits, and network requirements answer different questions. A complete review must use the rules that apply to the particular request. Reviewers stay within their assigned authority and refer cases that need further clinical review through the appropriate process.
Imagine a request arrives without a referenced visit note. The review begins with organizing what is present and identifying the missing information.
This example illustrates documentation and follow-up, not a coverage decision. The book expands on the review process with 16 fictional sample case reviews. You can also practice a mock prior authorization review.
Further reading: StatPearls: Utilization Management, NCQA utilization management, and ANA: the utilization management nurse role.
The book starts simple and never assumes you already know a term.
Each fictional educational case gives you the line of business, codes, sample clinical information, a guideline source, and a completed review note. The excerpt below illustrates the book format; it is not a current coverage determination.
05/27/2026 ================================================== Clinical Review: Pt. is referred for an attended in-laboratory polysomnography with CPAP titration due to documented obstructive sleep apnea and signs and symptoms consistent with sleep apnea. ================================================== CMS Local Coverage Determination (LCD) Polysomnography and Other Sleep Studies L36861 ================================================== Recommendations: MEETS. The treating provider documents obstructive sleep apnea with clinical signs and symptoms requiring an attended sleep study...
One of sixteen. Sleep studies, CPAP, spinal injections, power wheelchairs, MRIs, joint replacements, home health, SNF stays, bariatric surgery, cardiac devices, transplants, and more.
I was sick for a period of time, and suddenly I was the one in the gown, watching the nurses work. They'd see "LVN" in my chart and ask what kind of nursing I do. When I told them, utilization management, from home, still fully a nurse, the room would change. "Wait, from home? Do they hire LVNs? How do I learn it?"
Nurse after nurse, shift after shift, the same hungry questions. I answered as best I could between vitals checks, but those questions deserved more than a hallway answer. They deserved the whole map. So when I recovered, I wrote it.
This book is for all the nurses who want to learn more and leave bedside care.
Mr. Camara Starks, LVN
Ten-plus years in utilization management. Helped build a health plan from the ground up. Founder of ClearlyAuthReady.
ClearlyAuthReady lets you select a test and run mock authorization reviews built on the exact skills in this book. Practice before your interview. Sharpen after you're hired.
Try a Mock ReviewThe Nurse's Complete Guide to Utilization Management: Prior Authorizations, Criteria, Denials, DOFRs, and the Remote Nursing Career Nobody Told You About
The companion guide that started it all.
by Mr. Camara Starks, LVN
The original guide that introduced thousands of nurses to the world of utilization management. If you want the career overview and the mindset shift before diving into the technical deep-end, start here.
Get This Book on AmazonAvailable now on Amazon.
If you're burned out, injured, raising kids, or simply done with twelve-hour shifts, this is your proof that there's another room in the house of nursing.
Get the Book on Amazon