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Pediatric Utilization Review Jobs in Michigan (NOW HIRING)

Hope At Home Health Care

RN Field Case Manager

Oxford, MI · On-site

$100K/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

Troy, MI · On-site

$100K/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

Troy, MI · On-site

$100K/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

Wixom, MI · On-site

$100K/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

Troy, MI · On-site

$100K/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

Wixom, MI · On-site

$100K/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

Oxford, MI · On-site

$100K/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.

RN Field Case Manager

Hope At Home Health Care

Detroit, MI • On-site

$100K/yr

Full-time

Re-posted 21 days ago

Job description

We are looking for a compassionate RN to join our growing team! The right candidate has a can-do attitude, a friendly demeanor, excellent interpersonal skills, and the ability to provide medical support to our clients in their homes.
 

WHY BE A RN FIELD CASE MANAGER WITH HOPE AT HOME...

  • Earn upwards of $100k per year (based on full-time hours & must be able to drive to referrals within our service area)!!!
  • Flexible schedules (work days, nights, evenings, weekends - we'll work around your needs)!!!

So become a part of the Hope At Home Family and apply TODAY (serious applicants only)!

We currently have a position available for an experienced Home Health Care Registered Nurse! A RN with Mediport, PICC Line, Wound Care, and Infusion experience is greatly preferred.

The corporate office is located in Southfield, MI and the individual will provide RN support throughout our service area within the Tri-County area (Oakland, Macomb & Wayne).

A Registered Nurse administers skilled nursing care to patients on an intermittent basis in their place of residence. This is performed in accordance with physician orders and plan of care under the direction and supervision of the Clinical Manager/Nursing Supervisor.

QUALIFICATIONS:

  • Graduate of an approved school of professional nursing and currently licensed in the state of Michigan
  • One year nursing experience
  • Kinnser - EMR experience preferred
  • Home Healthcare experience preferred
  • Experience in Wound Vac, PICC line and Mediport care, preferred
  • Pediatric experience, desired

RESPONSIBILITIES:

  • Provides services in accordance with the plan of care.
  • Makes the initial evaluation visit and regularly reevaluates the patient's nursing needs.
  • Initiates the plan of care and necessary revisions.
  • Provides those services requiring substantial specialized nursing skills.
  • Initiates appropriate preventive and rehabilitative nursing procedures.
  • Prepares clinical and progress notes for each patient visit and summaries of care conferences on his/her patients in a timely manner as per Agency policy.
  • Coordinates services.
  • Inform personnel of changes in the condition and needs of the patient.
  • Counsels the patient and family/significant others in meeting nursing and related needs.
  • Participates in and presents in-service programs.
  • Understands and adheres to established Agency policies and procedures.
  • Processes orders and notifies physician of patient needs and changes in condition. Completes certification/recertification orders and discharge summaries.
  • Determines the amount and type of nursing needed by each individual patient.
  • Refers to Physical Therapist, Speech Language Pathologist, Occupational Therapist and Medical Social Worker those patients requiring their specialized skills.
  • Supervises and teaches other nursing personnel.
  • Conducts patient care conferences on patients assigned to his/her care.
  • Participates in peer review and performance improvement as assigned.
  • Participates in utilization review of medical records as assigned.
  • Gives total patient care as needed.
  • Takes on-call duty nights, weekends and holidays, as assigned.
  • Completes and submits OASIS assessments, reassessments, transfers, resumptions of care, discharges and significant change in condition in accordance with Agency defined time frames.
  • Appropriately utilizes ICD-10 codes.

WORKING ENVIRONMENT:
Works indoors in Agency office and patient homes and travels to/from patient homes.

 
HOPE At Home Health Care is a full service home care agency dedicated to helping people excel in the comfort of their home. We offer Medicare certified skilled services. Whether you are recovering from injury or illness, or simply want to reinvigorate your mobility and health, HOPE At Home Health Care has a solution for you.
 
We are an equal opportunity employer and prohibit discrimination/harassment without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.