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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 Minnesota?

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

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

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

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

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

Pediatric Utilization Review jobs near you
Infographic showing various Pediatric Utilization Review job openings in Minnesota as of August 2026, with employment types broken down into 89% Full Time, and 11% Part Time. Highlights an 100% In-person job distribution.

Manager (RN) - Utilization Review

Hennepin Healthcare

Minneapolis, MN • On-site

Full-time

Re-posted 28 days ago

Hennepin Healthcare rating

7.4

Company rating: 7.4 out of 10

Based on 44 frontline employees who took The Breakroom Quiz

264th of 898 rated healthcare providers

Job description

Hennepin Healthcare is an integrated system of care that includes HCMC, a nationally recognized Level I Adult Trauma Center and Level I Pediatric Trauma Center and acute care hospital, as well as a clinic system with primary care clinics located in Minneapolis and across Hennepin County. The comprehensive healthcare system includes a 473-bed academic medical center, a large outpatient Clinic & Specialty Center, and a network of clinics in the North Loop, Whittier, and East Lake Street neighborhoods of Minneapolis, and in the suburban communities of Brooklyn Park, Golden Valley, Richfield, and St. Anthony Village. Hennepin Healthcare has a large psychiatric program, home care, and operates a research institute, philanthropic foundation, and Hennepin EMS. The system is operated by Hennepin Healthcare System, Inc., a subsidiary corporation of Hennepin County.
Equal Employment Opportunities: We believe equity is essential for optimal health outcomes and are committed to achieve optimal health for all by actively eliminating barriers due to racism, poverty, gender identity, and other determinants of health. We are committed to equitable care and working in an environment that celebrates, promotes, and protects diversity, equity, inclusion, and belonging. We are committed to bringing in individuals with new cultural perspectives to assist in creating a more equitable healthcare organization.
JOB DETAILS
Department: Utilization Management
FTE: 1.0 (80 hours per pay period)
Shift(s): Days
Location: Remote with onsite presence as needed
Current List of non-MN States where Hennepin Healthcare is an Eligible Employer: Alabama, Arizona, Arkansas, Delaware, Florida, Georgia, Idaho, Illinois, Indiana, Iowa, Kansas, Louisiana, Mississippi, Nevada, North Carolina, North Dakota, New Mexico, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin.
We are currently seeking a Utilization Review Manager to join our Transitional Care Team. This is a full-time management role with remote capability.
Purpose of this position: Manages the design, development, implementation, and monitoring of utilization review functions. Oversees daily operations, which include supervising staff performing utilization management activities. The goal is to achieve clinical, financial, and utilization goals through effective management, communication, and role modeling. Functions as the internal resource on issues related to the appropriate utilization of resources, coordination of payer communication, and utilization review and management. Responsible for carrying out duties in a manner to assure success in financial management, human resources management, leadership, quality, and operational management objectives. Participates in program development and UR Department performance improvement. Responsible for day-to-day operations of the department, assists with the budgeting process, assists with personnel recruitment, retention, corrective action, and professional development.
RESPONSIBILITIES:
  • Participates in the development and management of department budgets and productivity targets
  • Directs and manages team of UR Coordinators, promotes employee satisfaction, supports staff development, and utilizes the progressive discipline process when appropriate
  • Collaborates with department director and professional development specialist to develop standard work and expectations for the utilization review process, including timely medical necessity screening to ensure patients are placed at the appropriate patient status and level of care, professional communication with physicians and nurses and other members of the care team
  • Collaborates with nursing, physicians, admissions, fiscal, legal, compliance, coding, and billing staff to answer clinical questions related to medical necessity and patient status
  • Ensures processes are in place for proactive reviews of surgical and other procedures to confirm accurate perioperative pre-authorization and patient class order reconciliation process. Assesses compliance to regulatory and health plan requirements for authorization, including Medicare
    Inpatient Only List and communicates to provider to obtain accurate order prior to procedure and post procedure
  • Ensures UR Coordinators and Clinical Coordinators identify, document, and communicate avoidable days and delays in services that may prolong length of stay; analyzes data to monitor trends for opportunities to improve services. Partners with hospital Director Transitional Care to report avoidable days, trends, and actions to UR Committees, as appropriate
  • Partners with Physician Advisor to engage in second level review and working with attending physicians to document completely to ensure patient class determinations
  • Serves as expert resource for all Medicare Notification Letters and ensures appropriate distribution of all letters (IMM, MOON, HINN, etc.) including full documentation to meet regulatory requirements and ensure correct billing
  • Works collaboratively with Inpatient Care Management, Patient Accounting, Patient Admission and Registration, HIM, and the Finance Department to analyze one-day Medicare inpatient stays and identify opportunities to improve
  • Develops and implements process to manage and respond to all concurrent and post-discharge third party payer denials of outpatient and inpatient cases alleged to be medically inappropriate. Including, but not limited to; Peer-to-Peer as appropriate, written appeal letters when indicated, documentation of interventions and outcomes and monitor to identify opportunities to improve processes for denial
    prevention
  • Serves as the internal expert on documentation and reimbursement requirements. Serves as a resource to the health care team for utilization and denial management. Liaises with provider office staff and facilitates meetings with payers, as appropriate
  • May participate in the Utilization Review Committee to present medical necessity data and outcomes and partners with care management leadership to develop action plans for improvement
  • Performs other duties as assigned

QUALIFICATIONS:
Minimum Qualifications:
  • Bachelors degree in nursing or related field
  • Three to five (3 to 5) years of leadership experience (i.e., charge nurse, team leader, preceptor, committee chair, etc.)
  • Five (5) years clinical experience.
  • A minimum of one (1) year of utilization review experience

Preferred Qualifications:
  • Masters' degree
  • CPHM (Certified Professional in Healthcare Management), CCM (Certified Case Manager), or ACM (Accredited Case Manager)
  • Experience in surgery, emergency and/or critical care
  • Experience in process/quality improvement, quality measurement, data abstraction, data analysis and reporting, and data integrity

Knowledge/ Skills/ Abilities:
  • Ability to deliver financial results for areas of accountability
  • Knowledge of or ability to learn financial management related to UR function and reporting, quality improvement processes, and human
    resources management
  • Able to effectively monitor, evaluate and administer the resources of each assigned area, and make substantiated recommendations regarding
    resource allocation needs for future planning purposes
  • Able to communicate effectively in writing and verbally, ability to interact with a wide variety of individuals, and handle complex and confidential
    situations
  • Ability to lead, delegate, analyze information and problem solve
  • Demonstrates evidence of strong skills in confidentiality, integrity, creativity, and initiative

License/Certifications:
  • Current Registered Nurse licensure from the Minnesota Board of Nursing upon hire

You've made the right choice in considering Hennepin Healthcare for your employment. We offer a wealth of opportunities for individuals who want to make an impact in our patients' lives. We are dedicated to providing Equal Employment Opportunities to both current and prospective employees. We are driven to connect talented individuals with life-changing career opportunities, enabling you to provide exceptional care without exception. Thank you for considering Hennepin Healthcare as a future employer.
Please Note: Offers of employment from Hennepin Healthcare are conditional and contingent upon successful clearance of all background checks and pre-employment requirements.

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