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Pediatric Utilization Review Jobs in Indiana (NOW HIRING)

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Pediatric Utilization Review information

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.

What are popular job titles related to Pediatric Utilization Review jobs in Indiana?

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

What job categories do people searching Pediatric Utilization Review jobs in Indiana look for?

The top searched job categories for Pediatric Utilization Review jobs in Indiana are:

What cities in Indiana are hiring for Pediatric Utilization Review jobs?

Cities in Indiana with the most Pediatric Utilization Review job openings:

Pediatric Utilization Review jobs near you
Infographic showing various Pediatric Utilization Review job openings in Indiana as of August 2026, with employment types broken down into 8% As Needed, 84% Full Time, and 8% Part Time. Highlights an 100% In-person job distribution.

Pediatrician

Anderson, IN

Jane Pauley Community Health Center, Inc.

7.5

Company rating: 7.5 out of 10

Based on 8 frontline employees who took The Breakroom Quiz

People enjoy working here

Good employer

Recommended by parents

Learn more about Jane Pauley Community Health Center, Inc.external

$147K - $190K/yr

Full-time

Re-posted 11 days ago

Job description

PediatricianSummary

The Pediatrician provides comprehensive, patient-centered pediatric care while supporting the clinical, operational, and quality goals of Jane Pauley Community Health Center (JPCHC). This role delivers direct clinical services, supervises care provided by clinical team members, and partners with practice leadership to ensure high-quality, compliant, and fiscally responsible care.

The Pediatrician actively participates in quality improvement initiatives, care coordination, and organizational programs that advance JPCHC's mission to provide accessible, integrated healthcare to the communities we serve.

Job Responsibilities (include but are not limited to):

Clinical Responsibilities

  • Provide direct pediatric services in accordance with JPCHC clinical standards, policies, and scope of practice.

  • Maintain full-time, on-site pediatric coverage as assigned.

  • Provide medical direction and supervision to clinical staff and other individuals delivering patient care under the Pediatrician's oversight.

  • Participate in equitable call coverage with other full-time JPCHC Pediatricians.

    • Call coverage will be assigned based on departmental need and will not exceed fifteen (15) days per month for more than two (2) consecutive months unless otherwise agreed upon.

    • Reasonable planning will occur in advance of scheduled leaves of absence.

  • Participate in patient satisfaction initiatives and surveys as requested.

  • Participate in managed care and third-party payer programs designated by JPCHC, including Medicare, Medicaid, and value-based or at-risk programs.

  • Utilize JPCHC inpatient and outpatient facilities and refer patients within the JPCHC network when appropriate, except when:

    • The patient expresses a preference for another provider;

    • Insurance requirements dictate referral outside the network; or

    • Referral is not in the patient's best interest based on professional medical judgment.

  • Perform additional pediatric duties as reasonably requested to support patient care and organizational needs.

Administrative & Leadership Responsibilities

  • Ensure compliance with all applicable licensing, regulatory, and accrediting body requirements at the practice site.

  • Assist with third-party billing matters, including Medicare, Medicaid, and commercial payer requirements, as needed.

  • Assume responsibility for supervising the clinical and professional care provided by non-physician staff working under the Pediatrician's direction.

  • Provide consultation and input on staffing, workflow, and operational decisions in collaboration with practice leadership (final decisions rest with JPCHC leadership).

  • Assist with recruitment, onboarding, and orientation of new physicians at the practice site.

  • Participate in quality assessment, utilization review, and quality improvement initiatives, including Medical Staff meetings and committees.

  • Support development and implementation of quality assurance, utilization review, and clinical pathway programs, integrating findings into clinical practice.

  • Contribute to fiscally responsible operations through participation in utilization review and quality assurance programs.

  • Support collaborative, team-based care models that improve patient outcomes, care coordination, and cost effectiveness.

  • Perform additional administrative duties as reasonably requested to support organizational goals.

Required Qualifications

  • MD or DO required

  • Board Certified or Board Eligible in Pediatrics

    • American Board of Pediatrics (ABP)

  • Active Indiana Medical License (or ability to obtain prior to start date)

  • Active DEA and Indiana Controlled Substance Registration (CSR) (or eligibility to obtain)

  • Commitment to serving underserved and diverse populations

  • Strong communication, leadership, and team collaboration skills

  • Experience in an FQHC, community health center, or safety-net setting preferred

 Why Join Us

You'll join a mission-driven organization committed to equitable access, integrated care, and continuous improvement. This role offers the opportunity to shape clinical excellence across multiple sites while supporting providers and teams serving diverse and underserved communities.

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