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Pediatric Utilization Management Jobs in Florida

Actalent

Remote Pediatric Case Manager RN

Orlando, FL

$40 - $44/hr

Collaborate with utilization management and care coordination teams to ensure services are ... pediatric members with varying levels of complexity. * Leverage Microsoft Office tools and care ...

Nemours

Pediatric Hospitalist, PRN

Jacksonville, FL · On-site

$176K - $224K/yr

The division of pediatric hospital medicine (PHM) provides comprehensive care to hospitalized ... utilization management, and clinical operations. Faculty are part of the VIP network and are ...

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Pediatric Utilization Management information

What is pediatric utilization management?

Pediatric Utilization Management (UM) is a healthcare process that reviews and evaluates the medical necessity, efficiency, and appropriateness of healthcare services provided to children. Professionals in this field assess treatment plans, hospital stays, procedures, and medications to ensure they align with evidence-based guidelines and are truly needed for a pediatric patient's care. The goal is to optimize health outcomes for children while managing healthcare costs and resources efficiently. Pediatric UM often involves collaboration between healthcare providers, insurance companies, and families to make informed decisions about a child's medical care.

What are some common challenges faced by professionals in pediatric utilization management, and how can they be addressed?

Professionals in Pediatric Utilization Management often encounter challenges such as balancing cost-effective care with the unique needs of pediatric patients, staying updated with evolving clinical guidelines, and communicating effectively with both providers and families. Navigating insurance requirements while advocating for appropriate treatments requires strong clinical knowledge and negotiation skills. Building collaborative relationships with multidisciplinary teams and ongoing professional development can help address these challenges and ensure the best outcomes for young patients.

What are the key skills and qualifications needed to thrive as a pediatric utilization management nurse, and why are they important?

To thrive in Pediatric Utilization Management, you need a solid background in pediatric nursing, critical thinking, and knowledge of healthcare regulations, generally supported by an RN license and experience in pediatrics. Familiarity with utilization review software, electronic medical records (EMRs), and certification such as Certified Case Manager (CCM) or Utilization Review Accreditation Commission (URAC) is often required. Excellent communication, attention to detail, and strong organizational skills are crucial for collaborating with medical teams and advocating for appropriate patient care. These competencies ensure effective care coordination, regulatory compliance, and optimal outcomes for pediatric patients.

What is the difference between Pediatric Utilization Management vs Pediatric Case Management?

AspectPediatric Utilization ManagementPediatric Case Management
CredentialsRN, licensed healthcare professionals, certifications in utilization reviewRN, social worker, case management certification
Work EnvironmentInsurance companies, healthcare organizations, utilization review departmentsHospitals, clinics, community health settings
Employer & Industry UsageInsurance providers, managed care organizationsHospitals, outpatient clinics, social services
FocusReviewing medical necessity, approving services, optimizing resource useCoordinating care, supporting patient needs, discharge planning

While both roles involve working with pediatric patients, Pediatric Utilization Management primarily focuses on reviewing and approving healthcare services for medical necessity within insurance or managed care settings. Pediatric Case Management emphasizes coordinating ongoing patient care and support services across healthcare providers and community resources.

What are popular job titles related to Pediatric Utilization Management jobs in Florida?

For Pediatric Utilization Management jobs in Florida, the most frequently searched job titles are:

What job categories do people searching Pediatric Utilization Management jobs in Florida look for?

The top searched job categories for Pediatric Utilization Management jobs in Florida are:

What cities in Florida are hiring for Pediatric Utilization Management jobs?

Cities in Florida with the most Pediatric Utilization Management job openings:

Pediatric Utilization Management jobs near you
Infographic showing various Pediatric Utilization Management job openings in Florida as of August 2026, with employment types broken down into 2% As Needed, 86% Full Time, 8% Part Time, and 4% Contract. Highlights an 98% In-person, and 2% Remote job distribution.

Utilization Review Specialist.

ELEMENT MEDICAL BILLING, LLC

Port Saint Lucie, FL • On-site

Full-time

Re-posted 27 days ago

Job description

Job Summary

We are seeking a highly motivated and detail-oriented Utilization Reviewer to join our dynamic healthcare team. In this pivotal role, you will evaluate medical records, clinical documentation, and patient care plans to ensure appropriate utilization of healthcare services. Your expertise will support clinical decision-making, promote compliance with regulatory standards, and optimize patient outcomes. The ideal candidate will possess a strong foundation in medical terminology, coding, and utilization management processes, with a passion for improving healthcare efficiency and quality.

Duties

Review medical documentation, including clinical notes, discharge summaries, and treatment plans to assess medical necessity and appropriateness of services.

Utilize advanced electronic health record (EHR) systems such as Epic, Cerner, Athenahealth, or eClinicalWorks to access and analyze patient information efficiently.

Apply knowledge of CPT coding, ICD-9/10 coding systems, DRGs (Diagnosis-Related Groups), and MDS (Minimum Data Set) to accurately classify diagnoses and procedures.

Conduct utilization reviews for inpatient and outpatient services across various settings including acute care hospitals, nursing homes, hospice care, emergency departments, PICUs (Pediatric Intensive Care Units), and Level I/II trauma centers.

Collaborate with multidisciplinary teams to facilitate discharge planning, case management, and clinical documentation improvement initiatives aligned with NCQA standards.

Ensure compliance with HIPAA regulations while handling sensitive patient information and medical records.

Participate in ongoing education related to managed care policies, Medicare/Medicaid guidelines, and evolving healthcare regulations to maintain current knowledge.

Experience

Proven experience in utilization review or utilization management within hospital or managed care environments.

Strong background in clinical settings such as ICU, emergency medicine, primary care, pediatrics, or nursing homes.

Familiarity with EMR/EHR systems like Epic, Cerner, Athenahealth or eClinicalWorks is essential for efficient workflow.

In-depth understanding of medical coding including CPT, ICD-9/10 codes, DRGs, and case management documentation standards.

Critical care experience or ICU background is highly desirable for assessing complex cases accurately.

Knowledge of Medicare regulations and NCQA standards to ensure compliance during reviews.

Excellent analytical skills combined with a thorough understanding of anatomy physiology and medical terminology to interpret complex clinical data effectively. Join us in making a meaningful impact on patient care by ensuring the appropriate use of healthcare resources! We are committed to fostering an inclusive environment that supports your professional growth while promoting work-life balance through comprehensive benefits designed to support your overall well-being.

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