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Pediatric Utilization Review Jobs in Michigan (NOW HIRING)

Corewell Health

RN Care Coordinator

Royal Oak, MI · On-site

It is a major academic and referral center with Level I adult and Level II pediatric trauma ... utilization review; care coordination; and/or discharge/transition planning). 2. Responsible for ...

Spectrum Health

RN Care Coordinator

Royal Oak, MI · On-site

It is a major academic and referral center with Level I adult and Level II pediatric trauma ... utilization review; care coordination; and/or discharge/transition planning). 2. Responsible for ...

Oaklawn Hospital

Intake Specialist

Marshall, MI · On-site

$17 - $23/hr

... and pediatric psychiatric patients. Experience working as an emergency department behavioral health evaluator preferred. Familiarity with pre-admission utilization review procedures, and case ...

Hope At Home Health Care

RN Field Case Manager

Pontiac, MI · On-site

$77K - $98K/yr

Pediatric experience, desired RESPONSIBILITIES: * Provides services in accordance with the plan of ... Participates in utilization review of medical records as assigned. * Gives total patient care as ...

Hope At Home Health Care

RN Field Case Manager

Clarkston, MI · On-site

$79K - $101K/yr

Pediatric experience, desired RESPONSIBILITIES: * Provides services in accordance with the plan of ... Participates in utilization review of medical records as assigned. * Gives total patient care as ...

Hope At Home Health Care

RN Field Case Manager

Pontiac, MI

$77K - $98K/yr

Pediatric experience, desired RESPONSIBILITIES: * Provides services in accordance with the plan of ... Participates in utilization review of medical records as assigned. * Gives total patient care as ...

Hope At Home Health Care

RN Field Case Manager

Clarkston, MI · On-site

$79K - $101K/yr

Pediatric experience, desired RESPONSIBILITIES: * Provides services in accordance with the plan of ... Participates in utilization review of medical records as assigned. * Gives total patient care as ...

Hope At Home Health Care

MI

$73K - $92K/yr

Pediatric experience, desired RESPONSIBILITIES: * Provides services in accordance with the plan of ... Participates in utilization review of medical records as assigned. * Gives total patient care as ...

Hope At Home Health Care

RN Field Case Manager

Novi, MI · On-site

$73K - $92K/yr

Pediatric experience, desired RESPONSIBILITIES: * Provides services in accordance with the plan of ... Participates in utilization review of medical records as assigned. * Gives total patient care as ...

Hope At Home Health Care

RN Field Case Manager

Howell, MI · On-site

$73K - $92K/yr

Pediatric experience, desired RESPONSIBILITIES: * Provides services in accordance with the plan of ... Participates in utilization review of medical records as assigned. * Gives total patient care as ...

Hope At Home Health Care

RN Field Case Manager

Gaines, MI

$65K - $83K/yr

Pediatric experience, desired RESPONSIBILITIES: * Provides services in accordance with the plan of ... Participates in utilization review of medical records as assigned. * Gives total patient care as ...

Hope At Home Health Care

RN Field Case Manager

Novi, MI · On-site

$73K - $93K/yr

Pediatric experience, desired RESPONSIBILITIES: * Provides services in accordance with the plan of ... Participates in utilization review of medical records as assigned. * Gives total patient care as ...

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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 Michigan?

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

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

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

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

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

Pediatric Utilization Review jobs near you
Infographic showing various Pediatric Utilization Review job openings in Michigan as of August 2026, with employment types broken down into 1% As Needed, 78% Full Time, 14% Part Time, 2% Temporary, 3% Contract, and 2% Nights. Highlights an 89% Physical, 3% Hybrid, and 8% Remote job distribution.

Quality Improvement Specialist PT Days

Tenet Healthcare Corporation

Detroit, MI • On-site

Part-time

Re-posted 14 days ago

Tenet Healthcare rating

6.2

Company rating: 6.2 out of 10

Based on 355 frontline employees who took The Breakroom Quiz

698th of 898 rated healthcare providers

Job description

Children’s Hospital of Michigan is an international leader in pediatric and adolescent medicine. Surgical services include general, thoracic, reconstructive and cardiovascular. Imaging technology designed specifically for children provides advanced diagnostic services including Positron Emission Tomography (PET) and MRI. The Children’s Hospital of Michigan Emergency Department is a verified Level 1 Pediatric Trauma Center and dedicated pediatric burn center. Experts in pediatric critical care, rehabilitation, and neonatal and perinatal medicine provide care for thousands of children every year at Children’s Hospital of Michigan, Children’s Hospital of Michigan - Troy and six ambulatory sites.

Job Summary

Under general direction and according to established policies and procedures, monitors patient care for quality assurance, utilization review and risk management activities. Determines appropriateness and medical necessity of admission, continued hospital stay and use of ancillary services. May perform pre-authorizations, concurrent review and retrospective review audits. 

May troubleshoot patient issues with Patient Management, as needed. Reviews and monitors patient medical records for complete, timely and accurate entries.

Communicates with third party payors and develops appeals to overturn adverse payment decisions; provides technical assistance to clinical and administrative staff regarding the development of quality improvement indicators/monitors, measurement methodology and charting techniques; conducts special studies and prepares report findings.

May participate in the development, education and maintenance of the DMC Continuous Improvement Program.

Facilitates the preparation of JCAHO and other licensing body requirements of accreditation. Develops and presents in-services to clinical and administrative staff regarding documentation and findings from reviews, as necessary. 

1. Bachelors degree in Nursing, Medical Records or health care field, or equivalent combination of education and/or related experience. Registered Nurse preferred.

2. Two to three years progressively more responsible clinical and/or Quality Assurance/utilization Review experience.

3. Coursework and experience in research statistics and quality improvement methodology, including chart control techniques, preferred. 

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