This role defines the responsibilities and requirements for registered nurses who evaluate the appropriateness and medical necessity of healthcare services. It outlines the qualifications, skills, and tasks associated with ensuring that patients receive the right care, in the right setting, at the right time. An example includes verifying that a hospital stay is warranted based on established clinical guidelines and the patient’s condition.
Proper performance of these duties leads to improved patient outcomes, cost containment for healthcare organizations, and compliance with regulatory standards. Historically, the need for this function arose from increasing healthcare costs and the desire to ensure efficient allocation of resources while maintaining quality patient care. This review process helps to avoid unnecessary procedures, hospitalizations, and other healthcare expenditures, thereby benefiting both patients and payers.
