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Pediatric Utilization Management Jobs (NOW HIRING)

TEEMA Group

Medical Director - Pediatrics

Phoenix, AZ · Remote

$140 - $145/hr

... utilization management, and provider engagement initiatives. This long-term opportunity allows you to leverage your extensive clinical expertise to shape pediatric healthcare delivery on a national ...

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Pediatric Utilization Management information

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$42

$68

How much do pediatric utilization management jobs pay per hour?

As of Jul 14, 2026, the average hourly pay for pediatric utilization management in the United States is $42.28, according to ZipRecruiter salary data. Most workers in this role earn between $33.41 and $48.56 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.
More about Pediatric Utilization Management jobs
What cities are hiring for Pediatric Utilization Management jobs? Cities with the most Pediatric Utilization Management job openings:
What states have the most Pediatric Utilization Management jobs? States with the most job openings for Pediatric Utilization Management jobs include:
What job categories do people searching Pediatric Utilization Management jobs look for? The top searched job categories for Pediatric Utilization Management jobs are:
Pediatric Utilization Management jobs near you
Infographic showing various Pediatric Utilization Management job openings in the United States as of July 2026, with employment types broken down into 1% As Needed, 82% Full Time, 14% Part Time, 1% Temporary, and 2% Contract. Highlights an 88% Physical, 2% Hybrid, and 10% Remote job distribution, with an average salary of $87,946 per year, or $42.3 per hour.
Associate Medical Director - Managed Care, Utilization Management

Associate Medical Director - Managed Care, Utilization Management

Texas Children's Hospital

Bellaire, TX • On-site

Full-time

Re-posted 23 days ago

Texas Children's Hospital rating

8.3

Company rating: 8.3 out of 10

Based on 174 frontline employees who took The Breakroom Quiz

78th of 1,020 rated hospitals

Job description


We're searching for an Associate Medical Director - Managed Care, Utilization Management, someone who's ready to be part of the best ranked children's hospital in Texas, and among the best in the nation. In this position, you will be responsible for establishing health plans and medical policies. The Associate Medical Director provides guidance to areas within departments of the Texas Children's Health Plan (TCHP); oversees assigned functions of the health plan; provides support, education, and consultation to Texas Children's System staff and physicians, regarding resource utilization, managed care and continuity of care issues.
Think you've got what it takes?
Job Duties & Responsibilities
  • Working with the CMOs and Medical Directors, you will oversee and provide recommendations to continuously improve the implementation of medical management programs as outlined in the policy and procedures. The programs include discharge planning; case and referral management; and the use of clinical protocols and medical review criteria. Working with the CMOs provides input into the development of standards for behavioral health care, practice guidelines, and medication management. Oversees the clinical professional review of behavioral health care by the registered nurses employed by the Health Plan and ensures regulatory compliance.
  • Working with the CMOs and Medical Director for Utilization Management, provides input into the development of medical care guidelines for utilization of behavioral health services. Completes medical necessity reviews and appeals of requests for medical care based upon evidence-based guidelines approved by the CAAC, using appropriate independent clinical judgment and not adversely influenced by fiscal management decisions. Documents denials of services not meeting medical necessity. Ensures that the UM Program reflects current philosophies in managed care and the stated values and goals of Texas Children's.
  • Working with the CMOs, develops guidelines and ensures office sites and medical records meet the standards for proper behavioral health care. Educates providers, as necessary. Supervises the use of physician profiles and educates the providers in the interpretation of these profiles.
  • Using data obtained through encounter and claims information, and electronic medical records from the group practices and hospital, monitors outcomes of members. This function is also done in conjunction with the CMOs, Medical Affairs Office and the Quality and Outcomes Management Department. Identifies strategies to affect outcomes.
  • Regulatory compliance and compliance with accreditation agencies -such as NCQA and TDI. Works with personnel in exceeding requirement of federal, state and accreditation agencies, and prepares for inspection and reviews by the above agencies.
  • Participate in other Committees as directed by the CMO's affecting patient care and medical policy, teaching programs and consults on managed care as necessary. Interacts with and participates in committees and medical functions of outside agencies to include primary HMOs, state and federal agencies, and professional organizations as directed by the CMOs.
  • Quality Management: Participates in the QM Program of the Health Plan, and the Quality Improvement Committee (QIC), the staff committee entrusted with all aspects of QM for the Health Plan. Collaborates with CMOs on establishing QI standards and assures their implementation and use. Ensures that approved medical protocols, rules of conduct and compliance with standards of public health is followed by Plan medical staff and providers. Monitor health status and outcomes of members.
  • Serves as a crucial member of the Health Plan operating team. Provides timely and accurate oral and written progress reports at staff meetings and to the CMO's. Demonstrates excellent communication and conflict resolution skills.

Skills & Requirements
  • Required Doctor of Medicine (M.D.) or Doctorate Doctor of Osteopathic Medicine (D.O.)
  • Required Licenses/Certifications
    • MDL - Medical Doctor License by the Texas Medical Board and BCPP - BC Physician in Psychiatry by the American Board of Psychiatry & Neurology or BCP - Cert-Board Cert Pediatrician by the American Board of Pediatrics or BCFM - Cert-Board Cert Family Medicine by the American Board of Family Medicine or BCOBGYN - Cert - Board Certified OB-GYN by the American Board of Medical Obstetrics and Gynecology
  • Required 5 years Healthcare management, managed care experience, and/or behavioral health experience
  • Residency in Psychiatry and Child Psychiatry training, when primary role of the Associate Medical Director is Behavioral Health
  • Candidates board certified in Pediatrics or Family Medicine are highly preferred

About Us
Founded in 1996, Texas Children's Health Plan is the nation's first health maintenance organization (HMO) created just for children. We provide STAR/Medicaid and Children's Health Insurance Program (CHIP) to pregnant women, teens, children and adults in Houston and surrounding areas. Currently, the Health Plan has more than 375,000 members who receive care from our network of more than 1,100 primary care physicians, 3,200 specialists, and 70 hospitals. Texas Children's Health Plan is also the largest combined STAR/CHIP Managed Care Organization in the Harris County service area.
To join our community of 15,000+ dedicated team members, visit texaschildrenspeople.org for career opportunities.
Texas Children's is proud to be an equal opportunity employer. All applicants and employees are considered and evaluated for positions at Texas Children's without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, gender identity, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.

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