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Pediatric Utilization Management Jobs in Raleigh, NC

Mgahomecare

Pediatric Nurse

Lillington, NC · On-site

... Manager. * Requests for modification of orders or additional orders are made based on the patient ... Appropriate utilization of all available services is demonstrated and documented. * Participation ...

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All JobsPediatric Utilization Management JobsPediatric Utilization Management Jobs in Raleigh, NC

Pediatric Utilization Management information

See Raleigh, NC salary details

$20

$41

$67

How much do pediatric utilization management jobs pay per hour?

As of Jul 29, 2026, the average hourly pay for pediatric utilization management in Raleigh, NC is $41.10, according to ZipRecruiter salary data. Most workers in this role earn between $32.50 and $47.21 per hour, depending on experience, location, and employer.

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 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 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 popular job titles related to Pediatric Utilization Management jobs in Raleigh, NC? For Pediatric Utilization Management jobs in Raleigh, NC, the most frequently searched job titles are:
What job categories do people searching Pediatric Utilization Management jobs in Raleigh, NC look for? The top searched job categories for Pediatric Utilization Management jobs in Raleigh, NC are:
What cities near Raleigh, NC are hiring for Pediatric Utilization Management jobs? Cities near Raleigh, NC with the most Pediatric Utilization Management job openings:
Pediatric Utilization Management jobs near you

Pediatric Cardiac Stepdown Advanced Practice Provider (APP)

Duke Health

Durham, NC • On-site

Full-time

Posted 21 days ago

Duke Health rating

7.3

Company rating: 7.3 out of 10

Based on 251 frontline employees who took The Breakroom Quiz

307th of 890 rated healthcare providers

Job description

At Duke Health, we're driven by a commitment to compassionate care that changes the lives of patients, their loved ones, and the greater community. No matter where your talents lie, join us and discover how we can advance health together.
About Duke University Hospital
Pursue your passion for caring with Duke University Hospital in Durham, North Carolina, which is consistently ranked among the best in the United States. The largest of the four Duke Healthhospitals with 1062 patient beds, it features comprehensive diagnostic and therapeutic facilities, including a regional emergency/trauma center, an endo-surgery center, and more.
Duke University Hospital
Center for Advanced Practice
Pediatric Cardiac Stepdown Advanced Practice Provider (APP)
Nurse Practitioner or Physician Assistant
Job Location
Duke University Hospital
Job Summary
The Duke Hospital Pediatric Cardiac Stepdown Advanced Practice Provider (APP), including both Nurse Practitioner (NP) and/or Physician Assistant (PA), provides direct patient care services for critically ill pediatric patients aged 0-21 with acute, complex, and chronic illness across a variety of care settings. It is appropriate for the NP to provide care for an aging pediatric patient beyond the age of 21 with a pediatric condition for a limited period of time.
Utilizing acquired knowledge of physiology, pathophysiology and pharmacology, the Pediatric Cardiac Stepdown APP exercises independent decision making in the assessment, diagnosis and development of the plan of care for patients on the Pediatric Cardiac stepdown service. In collaboration and consultation with the supervising physician, the APP contributes to excellence in patient care.As an advanced practice provider, the APP is additionally involved in education, consultation, research and leadership throughout the Duke Health System, organization and profession.
Job Duties and Responsibilities
Clinical Expert
  • In collaboration with the attending of service and/or residents, round daily on patients to assess, diagnose, plan treatment, set priorities and realistic outcomes, and evaluate the effectiveness and cost efficiency of patient care.
  • Provide and coordinate clinical care for service specific patients through established protocols and under the hospitalist supervising physician or back up physician who is either on site or available by pager.
  • Collaborate with the chief resident, residents, fellows, attending other APP colleagues, nurses, and patient resource managers to formulate treatment plans and monitor patient progress.
  • Perform procedures specific to the work environment after demonstrated competency and within the guidelines of scope of practice and credentialing protocols.
  • Assess patients for change in status and institute appropriate interventions. Initiate emergency interventions in an effort to stabilize the patient until physician support arrives.
  • Postoperative stabilization and management.
  • Develop patient care pathways, protocols and guidelines for the management of specific problems in conjunction with physicians and other members of the health care team.
  • Analyze clinical practice patterns so as to provide the best medical care and to increase effectiveness and efficiency.
  • Communicate verbally and in writing all pertinent patient information to supervising MD, nursing staff, patient resource manager, home health agency, and other relevant healthcare providers.
  • Document in the patients' medical record all relevant data including but not limited to results of diagnostic tests; laboratory results; patients' condition and response to therapies/interventions; communications with supervising MD.
  • Utilize prescriptive privileges only for identified patient population.
  • Prescriptive authority for prescribing, ordering, and or administering drugs; including (but not limited to) schedule II, III, IV, and V drugs and necessary medical devices.
  • Role model competence in all nurse practitioner / physician assistant advanced skills.
  • Give daily handoff to appropriate attending, APP, resident and/or intern at the end of the shift.

Educator:
  • Assess educational needs of the patient-care staff and provide one-on-one as well as formal education as needed.
  • Assess educational needs of the patients / families and provide culturally-sensitive patient/family education interventions as indicated.Use non-technical language when educating patients and families.Document all education in patients' medical record.
  • Implement and evaluate appropriate educational programs for DUHS patient care staff and other healthcare providers as appropriate.
  • Role model and precept healthcare learners through contractual agreements.

Research Utilization and Investigation:
  • Utilize current research and evidence-based decision-making in all clinical practice.
  • Incorporate clinical research findings in the development and implementation of standards of care.
  • Support IRB approved clinical research/trials though a variety of activities including but not limited to: obtaining consent; ordering diagnostic tests; recording laboratory & diagnostic results; administering therapeutic interventions; and reporting patient outcomes including toxicities or adverse events.
  • Participate in interdisciplinary quality improvement and/or research activities.
  • Participate in measuring and documenting outcomes.

Consultant:
  • Provide expertise and resource information to other healthcare providers, patients and families, and the community at large related to pediatric diseases, procedures, interventions, and conditions.
  • Implement and evaluate appropriate educational programs for referring MDs
  • Develop, implement and evaluate standards of care/practice guidelines/policies and procedures/care maps/protocols within area of specialization.
  • Develop programs and projects in areas of expertise to facilitate the attainment of the goals and objectives of the Duke University Hospital and Duke University Health System.

Professional Leadership and Development:
  • Role model advanced practice professionalism through conduct, communication, dress, leadership, ethical decision-making, critical thinking and problem solving skills.
  • Participate in at least one professional organization.
  • Demonstrate responsibility for professional practice through active participation in the CAP, and professional organizations.Meet Continuing Education requirements as designated by the NC Medical Board and/or NC Nursing Board.Maintain professional certification.
  • Enhance the body of knowledge in area of specialization through written publications, oral presentations, posters, continuing education, etc.
  • Maintain all professional requirements for licensure and certification

Job Eligibility Requirements
Education
NP:Graduate of an accredited MSN or DNP Acute Care Pediatric Nurse Practitioner program.
PA:Graduate of an ARC accredited Physician Assistant program.
Licensure
NP:Current unrestricted RN licensure issued by or recognized by the NCBON with authorization to practice as an NP
PA: Current unrestricted medical license issued by the NCMB with authorization to practice as a PA
Certification
NP:National certification as an NP (PNP-AC is the only certification accepted)
PA:PA-C
Experience
Prior experience as a Nurse Practitioner/Physician Assistant in a pediatric acute care clinical setting strongly preferred with preference for a cardiac-specific background. Registered Nurses with at least 2 years of pediatric cardiac nursing experience preferred.
Physical and mental requirements
  • Able to clearly articulate scope of practice, and practices within those guidelines as a Nurse Practitioner / Physician Assistant in the state of North Carolina and within the Duke University Health System.
  • Able to independently seek out resources and work collaboratively to solve complex problems
  • Able to communicate clearly with patients, families, visitors, healthcare team, physicians, administrators, leadership, and others.
  • Able to use sensory and cognitive functions to process and prioritize information, perform health assessments, treatment, and follow-up.
  • Able to use fine motor skills
  • Able to record activities, document assessments & interventions; prepare reports and presentations
  • Able to use computer and learn new software programs
  • Able to provide leadership in clinical area of expertise and in meeting organizational goals
  • Able to navigate the Hospital and DUHS to provide clinical expertise to specific patient populations
  • Able to withstand prolonged standing and walking with the ability to move or lift at least fifty pounds
  • Able to remain focused and organized
  • Able to work collaboratively with all levels of personnel

Job Hours
12-hour shifts to provide day and night coverage 7 days a week including holidays. Rotating schedule, nocturnist (nights-only) schedule, and weekend-only schedule options available.
Duke is an Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex (including pregnancy and pregnancy related conditions), sexual orientation or military status.
Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas-an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.
Essential Physical Job Functions:
Certain jobs at Duke University and Duke University Health System may include essential job functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.

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