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Pediatric Utilization Review Jobs in Florida (NOW HIRING)

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Pediatric Utilization Review information

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 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 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 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.

What are popular job titles related to Pediatric Utilization Review jobs in Florida? For Pediatric Utilization Review jobs in Florida, the most frequently searched job titles are:
What job categories do people searching Pediatric Utilization Review jobs in Florida look for? The top searched job categories for Pediatric Utilization Review jobs in Florida are:
What cities in Florida are hiring for Pediatric Utilization Review jobs? Cities in Florida with the most Pediatric Utilization Review job openings:
Pediatric Utilization Review jobs near you
Infographic showing various Pediatric Utilization Review job openings in Florida as of May 2026, with employment types broken down into 3% As Needed, 83% Full Time, and 14% Part Time. Highlights an 95% In-person, and 5% Remote job distribution.
Utilization Review Clinician-BHC

Utilization Review Clinician-BHC

Tallahassee Memorial Healthcare

Tallahassee, FL • On-site

$52.40K - $71.80K/yr

Full-time

Posted 10 hours ago

Tallahassee Memorial HealthCare rating

6.6

Company rating: 6.6 out of 10

Based on 63 frontline employees who took The Breakroom Quiz

554th of 864 rated healthcare providers

Job description

WHO WE ARE & WHAT WE DO
Tallahassee Memorial Healthcare (TMH) is a private, nonprofit community-based healthcare system that provides care to a 22-county region in North Florida and South Georgia. We are a career destination with over 6,000 colleagues who reflect the diversity of our community.
TMH is the region's healthcare leader and top provider of advanced care with a 772-bed acute care hospital and the region's only:
  • Level II Trauma Center
  • Primary Stroke Center
  • Level III Neonatal Intensive Care
  • Pediatric Intensive Care
  • The most advanced cancer, heart and vascular, orthopedic & surgery programs in the Panhandle.

Our system also includes a psychiatric hospital, multiple specialty care centers, six residency programs and more than 50 affiliated physician practices.
HOW YOU'LL MAKE AN IMPACT
Your Role:
  • Conducts ongoing pre-certification, concurrent, and retrospective reviews on the Tallahassee Memorial Behavioral Health Center (TMBHC) inpatient population.
  • Coordinates reviews with the respective insurance companies for which the medical necessity for initial admission certifications and continued stays are determined.
  • Liaises between the Business Office, insurance companies, and attending psychiatrists.

Reports To: Director/BHC Operations (JC: 015601)
Supervises: None.
WHAT YOU'LL NEED TO APPLY
Required Education:
  • Bachelor's degree in a field of nursing, counseling, social work, psychology, or a related human services field

Preferred Education:
  • Current enrollment in a master's degree program or master's degree in a mental health specialty (e.g., Master of Social Work, Masters of Mental Health, Master of Mental Health Counseling, or Masters of Marriage and Family Therapy).

Required Experience:
  • Two (2) years of relevant job-related experience

Preferred Experience:
  • Two (2) to five (5) years of relevant job-related experience

Required Certification/License/Registry:
  • None

Preferred Certification/License/Registry:
  • Licensed as a registered nurse (RN) in accordance with Florida Statutes (F.S.), Title XXXII (Regulation of Professions and Occupations), Chapter 464 (Nursing), Part I (Nurse Practice Act) [includes multistate compact licensure] or licensed as a mental health professional (e.g., Licensed Clinical Social Worker (LCSW), Licensed Mental Health Counselor (LMHC), or Licensed Marriage and Family Therapist (LMFT)) in accordance with F.S., Title XXXII, Chapter 491 (Clinical, Counseling, and Psychotherapy Services)

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Tallahassee Memorial HealthCare is an equal opportunity employer and drug-free workplace. All employment is contingent upon successful completion of a drug screen, background check, reference verification, health assessment, and credential/license verification.

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