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Pediatric Utilization Review Jobs (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 ...

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Pediatric Utilization Review information

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How much do pediatric utilization review jobs pay per hour?

As of Jul 29, 2026, the average hourly pay for pediatric utilization review 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.

Can you become a utilization reviewer without being a nurse?

Pediatric utilization review roles typically require a nursing background or healthcare-related experience, as they involve assessing medical necessity and reviewing patient care. While some positions may accept other healthcare professionals with relevant training or certifications, most employers prefer candidates with nursing credentials or clinical experience. Knowledge of medical coding, insurance policies, and utilization review software is also beneficial.

What are some common challenges faced by pediatric utilization review professionals, and how are they addressed?

Pediatric utilization review professionals often encounter challenges such as balancing the need for cost-effective care with advocating for the unique clinical needs of children. They must navigate complex insurance guidelines while collaborating closely with physicians, case managers, and families to ensure children receive appropriate and timely care. Staying updated on evolving pediatric treatment protocols and regulatory requirements is also essential. Strong communication skills and a thorough understanding of pediatric standards help address these challenges and promote positive patient outcomes.

How to become a utilization review specialist?

To become a utilization review specialist, typically one needs a relevant healthcare background such as nursing, health administration, or a related field, along with experience in medical coding or insurance. Certification such as the Certified Professional in Healthcare Quality (CPHQ) or a similar credential can enhance job prospects, and strong analytical and communication skills are essential for reviewing medical necessity and treatment plans.

What is the highest paid pediatric job?

In pediatric healthcare, pediatric specialists such as pediatric cardiologists, pediatric intensivists, and pediatric surgeons tend to have the highest salaries. Pediatric utilization review roles generally offer competitive pay, but specialized physicians in pediatric subspecialties typically earn the highest compensation within pediatric jobs.

What are alternative careers with a pediatric background?

With a pediatric background, alternative careers include pediatric nurse, child life specialist, pediatric social worker, pediatric physical or occupational therapist, and pediatric healthcare administrator. These roles often require relevant certifications, clinical experience, and knowledge of child development and healthcare policies.

What is pediatric utilization review?

Pediatric utilization review is a process in healthcare where specialists assess the necessity, appropriateness, and efficiency of medical services provided to children. The goal is to ensure that pediatric patients receive the right care at the right time, while avoiding unnecessary treatments or procedures. Utilization review professionals review medical records, treatment plans, and insurance information to make informed decisions about coverage and care. This process helps control healthcare costs and maintain high standards of care for young patients.

What are the key skills and qualifications needed to thrive as a Pediatric Utilization Review nurse, and why are they important?

To excel as a Pediatric Utilization Review nurse, you need a solid clinical background in pediatrics, a current RN license, and knowledge of healthcare regulations and insurance guidelines. Familiarity with utilization management software, electronic health records (EHRs), and industry certifications like Certified Case Manager (CCM) are often required. Strong analytical skills, attention to detail, and effective communication help you collaborate with healthcare teams and advocate for appropriate care. These competencies ensure that pediatric patients receive necessary, cost-effective treatment while maintaining compliance with regulatory standards.

What is the difference between Pediatric Utilization Review vs Pediatric Case Manager?

AspectPediatric Utilization ReviewPediatric Case Manager
CredentialsTypically requires nursing or healthcare-related certificationsRequires nursing, social work, or healthcare certifications
Work EnvironmentReviewing medical records and insurance claims, often remotely or in officeDirect patient interaction, coordinating care, often in clinical or community settings
Employer & IndustryHospitals, insurance companies, healthcare organizationsHospitals, clinics, community health agencies

While both roles focus on pediatric healthcare, Pediatric Utilization Review primarily involves evaluating medical necessity and insurance claims, whereas Pediatric Case Managers coordinate ongoing patient care and support families directly. Understanding these differences helps in choosing the right career path or job search focus.

More about Pediatric Utilization Review jobs
What cities are hiring for Pediatric Utilization Review jobs? Cities with the most Pediatric Utilization Review job openings:
What states have the most Pediatric Utilization Review jobs? States with the most job openings for Pediatric Utilization Review jobs include:
What job categories do people searching Pediatric Utilization Review jobs look for? The top searched job categories for Pediatric Utilization Review jobs are:
Pediatric Utilization Review jobs near you
Infographic showing various Pediatric Utilization Review job openings in the United States as of July 2026, with employment types broken down into 1% Locum Tenens, 3% As Needed, 71% Full Time, 17% Part Time, and 8% Contract. Highlights an 98% Physical, and 2% Remote job distribution, with an average salary of $87,946 per year, or $42.3 per hour.
Utilization Review Specialist

Utilization Review Specialist

ELEMENT MEDICAL BILLING, LLC

Port Saint Lucie, FL • On-site

Full-time

Posted 2 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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