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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 ...

Albany Medical Center

Utilization Review Nurse

Albany, NY · On-site

$77K - $119K/yr

... utilization review identifies areas for clinical documentation improvement and contacts appropriate ... pediatric trauma centers, and only children's hospital. Thedowntown campus also offers ...

Bestica Healthcare

RN Utilization Review

Tuba City, AZ · On-site

Utilization Review Nurse Full compliance is required 2 weeks prior to the start date. Hospital ... Dental staff includes general dentists, endodontists, oral and maxillofacial surgeons, pediatric ...

Providence Health & Service

Utilization Review RN

Utilization Review RN - Remote Utilization Review RN - REMOTE position. This position is Part time ... care, pediatrics and neonatal intensive care. Our not-for-profit network provides a full spectrum ...

Providence Service

Utilization Review RN

Portland, OR · On-site

Description Utilization Review RN at Providence Health Plaza. Utilization Management covers 7 days ... care, pediatrics and neonatal intensive care. Our not-for-profit network also provides a full ...

Providence Service

Utilization Review RN

Portland, OR · On-site

Description Utilization Review RN at Providence Health Plaza. Utilization Management covers 7 days ... care, pediatrics and neonatal intensive care. Our not-for-profit network also provides a full ...

Providence Service

Utilization Review RN

Portland, OR · On-site

Description Utilization Review RN at Providence Health Plaza. Utilization Management covers 7 days ... care, pediatrics and neonatal intensive care. Our not-for-profit network also provides a full ...

Providence Service

Utilization Review RN

Irvine, CA · On-site

Description Utilization Review RN - REMOTE position. This position is Part time and will work 8- ... care, pediatrics and neonatal intensive care. Our not-for-profit network provides a full spectrum ...

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Pediatric Utilization Review information

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How much do pediatric utilization review jobs pay per hour?

As of Sep 14, 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.

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 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.

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 are popular job titles related to Pediatric Utilization Review jobs?

For Pediatric Utilization Review jobs, the most frequently searched job titles are:

Pediatric Utilization Review jobs near you
Infographic showing various Pediatric Utilization Review job openings in the United States as of September 2026, with employment types broken down into 1% As Needed, 81% Full Time, 16% Part Time, and 2% Contract. Highlights an 87% Physical, 3% Hybrid, and 10% Remote job distribution, with an average salary of $87,946 per year, or $42.3 per hour.

Utilization Review Specialist.

Port Saint Lucie, FL • On-site

ELEMENT MEDICAL BILLING, LLC
Finance and Insurance • 11 - 50 employees
Learn more about ELEMENT MEDICAL BILLING, LLCexternal

Full-time

Re-posted 19 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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