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Pediatric Utilization Management Jobs in Ohio (NOW HIRING)

Nationwide Children's Hospital

One year of experience in pediatric care or services, required. * Utilization review or utilization management experience, preferred. Physical Requirements: OCCASIONALLY: Bend/twist, Climb stairs ...

Akron Children's Hospital

Payer Policy Coordinator

Akron, OH · On-site

$18.50 - $24.75/hr

... utilization management required. Experience in a children's hospital, pediatric specialty practice, or managed care environment is strongly preferred. 5. Years of supervisory experience: None ...

Nationwide Children's Hospital

At least one year in pediatric nursing is highly preferred. * Nursing experience may include inpatient nursing, case management, utilization review, discharge planning, community health nursing.

Nationwide Children's Hospital

At least one year in pediatric nursing is highly preferred. * Nursing experience may include inpatient nursing, case management, utilization review, discharge planning, community health nursing.

New

Nationwide Children's Hospital

At least one year in pediatric nursing is highly preferred. * Nursing experience may include inpatient nursing, case management, utilization review, discharge planning, community health nursing.

Nationwide Children's Hospital

At least one year in pediatric nursing is highly preferred. * Nursing experience may include inpatient nursing, case management, utilization review, discharge planning, community health nursing.

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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 Ohio?

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

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

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

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

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

Pediatric Utilization Management jobs near you
Infographic showing various Pediatric Utilization Management job openings in Ohio as of August 2026, with employment types broken down into 87% Full Time, 7% Part Time, 3% Contract, and 3% Summer. Highlights an 90% In-person, 3% Hybrid, and 7% Remote job distribution.

Utilization Review Specialist - Autism

Nationwide Children's Hospital

Hybrid

Full-time

Re-posted yesterday

Nationwide Children's Hospital rating

6.9

Company rating: 6.9 out of 10

Based on 131 frontline employees who took The Breakroom Quiz

548th of 1,062 rated hospitals

Job description

Overview:


Schedule: Monday-Friday (8:00am-4:30pm)

Position is work from home after a 90 day in-office training period.


Job Description Summary:


Reviews behavioral health cases to determine medical necessity and appropriateness of care, ensuring compliance with established guidelines and policies. Performs pre-certifications, pre-authorizations, re-authorization, concurrent utilization reviews, retrospective reviews, and denial management. Interacts with staff and departments of the hospital to facilitate appropriate, cost-effective patient care.


Job Description:


Essential Functions:

  • Conducts utilization reviews of behavioral health cases to determine medical necessity, appropriateness of care, and adherence to clinical guidelines.
  • Communicates with healthcare teams and third-party payors to ensure the delivery of quality care and optimum payment.
  • Assists with retrospective reviews and denial management to maintain appropriate and cost-effective patient care.
  • Documents all case reviews and maintains accurate records of all clinical activities and coverage information.
  • Provides education and support regarding utilization review and management activities and processes.
  • Analyzes clinical data to identify trends and patterns that may impact patient care. Participates in quality improvement initiatives to enhance the overall delivery of behavioral health services.
  • Facilitates reimbursement by communicating with payers, other staff, patients, and families concerning status of funding and required actions.


Education Requirement:

Bachelor's Degree in Social Work, Psychology, or related field, required.


Licensure Requirement:

(not specified)


Certifications:

(not specified)


Skills:

  • Excellent written and verbal communication and interpersonal skills.
  • Excellent customer service and organizational skills.
  • Working knowledge of CMS and other review agency standards.
  • Proficient with software applications including CM, payer web applications, MITS, and others.


Experience:

  • Three years of behavioral health experience, required.
  • One year of experience in pediatric care or services, required.
  • Utilization review or utilization management experience, preferred.


Physical Requirements:

OCCASIONALLY: Bend/twist, Climb stairs/ladder, Flexing/extending of neck, Lifting / Carrying: 0-10 lbs, Reaching above shoulder, Squat/kneel

FREQUENTLY: Standing, Walking

CONTINUOUSLY: Audible speech, Color vision, Computer skills, Decision Making, Depth perception, Hand use: grasping, gripping, turning, Hearing acuity, Interpreting Data, Peripheral vision, Problem solving, Repetitive hand/arm use, Seeing - Far/near, Sitting


Additional Physical Requirements performed but not listed above:

(not specified)




"The above list of duties is intended to describe the general nature and level of work performed by individuals assigned to this classification. It is not to be construed as an exhaustive list of duties performed by the individuals so classified, nor is it intended to limit or modify the right of any supervisor to assign, direct, and control the work of employees under their supervision. EOE M/F/Disability/Vet"

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About Nationwide Children's Hospital

Sourced by ZipRecruiter

Nationwide Children's Hospital, established in 1894, is a leading pediatric healthcare system based in Columbus, Ohio, United States. They serve as a primary pediatric network, providing wellness, preventive, diagnostic, treatment, and rehabilitative care for infants, children, adolescents, and adults with congenital disease. Being the third-largest pediatric hospital in the nation, Nationwide Children's Hospital prides itself on its relentless commitment to children and their families, driven by their core values of respect, integrity, determination, empathy, and solidarity. The institution's comprehensive mission is to enhance the health of children by providing high-quality, family-centered care, conducting groundbreaking research, advocating for pediatric health, and training top healthcare professionals.

Industry

Hospitals

Company size

10,000+ Employees

Headquarters location

Columbus, OH, US

Year founded

1892

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