One year of experience in pediatric care or services, required. * Utilization review or utilization management experience, preferred. Physical Requirements: OCCASIONALLY: Bend/twist, Climb stairs ...
One year of experience in pediatric care or services, required. * Utilization review or utilization management experience, preferred. Physical Requirements: OCCASIONALLY: Bend/twist, Climb stairs ...
One year of experience in pediatric care or services, required. * Utilization review or utilization management experience, preferred. Physical Requirements: OCCASIONALLY: Bend/twist, Climb stairs ...
One year of experience in pediatric care or services, required. * Utilization review or utilization management experience, preferred. Physical Requirements: OCCASIONALLY: Bend/twist, Climb stairs ...
Utilization Review Specialist - Autism
Columbus, OH · On-site
$60 - $80/hr
One year of experience in pediatric care or services, required.Utilization review or utilization management experience, preferred.Physical Requirements:OCCASIONALLY: Bend/twist, Climb stairs/ladder ...
Utilization Review Specialist - Autism
Columbus, OH · On-site
$60 - $80/hr
One year of experience in pediatric care or services, required.Utilization review or utilization management experience, preferred.Physical Requirements:OCCASIONALLY: Bend/twist, Climb stairs/ladder ...
Registered Nurse, Care Coordinator - Cerebral Palsy (PFK)
Columbus, OH · On-site
$60 - $80/hr
At least one year in pediatric nursing is highly preferred. Nursing experience may include inpatient nursing, case management, utilization review, discharge planning, community health nursing.
Registered Nurse, Care Coordinator - Cerebral Palsy (PFK)
Columbus, OH · On-site
$60 - $80/hr
At least one year in pediatric nursing is highly preferred. Nursing experience may include inpatient nursing, case management, utilization review, discharge planning, community health nursing.
At least one year in pediatric nursing is highly preferred. * Nursing experience may include inpatient nursing, case management, utilization review, discharge planning, community health nursing.
At least one year in pediatric nursing is highly preferred. * Nursing experience may include inpatient nursing, case management, utilization review, discharge planning, community health nursing.
At least one year in pediatric nursing is highly preferred. * Nursing experience may include inpatient nursing, case management, utilization review, discharge planning, community health nursing.
At least one year in pediatric nursing is highly preferred. * Nursing experience may include inpatient nursing, case management, utilization review, discharge planning, community health nursing.
At least one year in pediatric nursing is highly preferred. * Nursing experience may include inpatient nursing, case management, utilization review, discharge planning, community health nursing.
At least one year in pediatric nursing is highly preferred. * Nursing experience may include inpatient nursing, case management, utilization review, discharge planning, community health nursing.
Registered Nurse Care Coordinator - Fostering Connections Clinic (PFK)
Columbus, OH · On-site
$60 - $80/hr
At least one year in pediatric nursing is highly preferred.Nursing experience may include inpatient nursing, case management, utilization review, discharge planning, community health nursing.
Registered Nurse Care Coordinator - Fostering Connections Clinic (PFK)
Columbus, OH · On-site
$60 - $80/hr
At least one year in pediatric nursing is highly preferred.Nursing experience may include inpatient nursing, case management, utilization review, discharge planning, community health nursing.
At least one year in pediatric nursing is highly preferred. * Nursing experience may include inpatient nursing, case management, utilization review, discharge planning, community health nursing.
At least one year in pediatric nursing is highly preferred. * Nursing experience may include inpatient nursing, case management, utilization review, discharge planning, community health nursing.
At least one year in pediatric nursing is highly preferred. * Nursing experience may include inpatient nursing, case management, utilization review, discharge planning, community health nursing.
At least one year in pediatric nursing is highly preferred. * Nursing experience may include inpatient nursing, case management, utilization review, discharge planning, community health nursing.
At least one year in pediatric nursing is highly preferred. * Nursing experience may include inpatient nursing, case management, utilization review, discharge planning, community health nursing.
At least one year in pediatric nursing is highly preferred. * Nursing experience may include inpatient nursing, case management, utilization review, discharge planning, community health nursing.
At least one year in pediatric nursing is highly preferred. * Nursing experience may include inpatient nursing, case management, utilization review, discharge planning, community health nursing.
At least one year in pediatric nursing is highly preferred. * Nursing experience may include inpatient nursing, case management, utilization review, discharge planning, community health nursing.
At least one year in pediatric nursing is highly preferred. * Nursing experience may include inpatient nursing, case management, utilization review, discharge planning, community health nursing.
At least one year in pediatric nursing is highly preferred. * Nursing experience may include inpatient nursing, case management, utilization review, discharge planning, community health nursing.
At least one year in pediatric nursing is highly preferred. * Nursing experience may include inpatient nursing, case management, utilization review, discharge planning, community health nursing.
At least one year in pediatric nursing is highly preferred. * Nursing experience may include inpatient nursing, case management, utilization review, discharge planning, community health nursing.
At least one year in pediatric nursing is highly preferred. * Nursing experience may include inpatient nursing, case management, utilization review, discharge planning, community health nursing.
At least one year in pediatric nursing is highly preferred. * Nursing experience may include inpatient nursing, case management, utilization review, discharge planning, community health nursing.
Family Practice Physician Outpatient Only Practitioner - Physicians Only Apply - Perm
Columbus, OH · On-site
$215K - $344K/yr
Performs medical review activities pertaining to utilization review, quality assurance, and medical ... Pediatrics or Emergency Medicine). The candidate must be an actively practicing physician. Need 3-5 ...
Family Practice Physician Outpatient Only Practitioner - Physicians Only Apply - Perm
Columbus, OH · On-site
$215K - $344K/yr
Performs medical review activities pertaining to utilization review, quality assurance, and medical ... Pediatrics or Emergency Medicine). The candidate must be an actively practicing physician. Need 3-5 ...
Registered Nurse Care Coordinator - Fostering Connections Clinic (PFK)
Columbus, OH · On-site
$60 - $80/hr
At least one year in pediatric nursing is highly preferred. * Nursing experience may include inpatient nursing, case management, utilization review, discharge planning, community health nursing.
Registered Nurse Care Coordinator - Fostering Connections Clinic (PFK)
Columbus, OH · On-site
$60 - $80/hr
At least one year in pediatric nursing is highly preferred. * Nursing experience may include inpatient nursing, case management, utilization review, discharge planning, community health nursing.
Reviews hearing rights for appropriateness and submits them for processing to ensure compliance ... of either pediatric, Developmental Disabilities or mental health experience within the last ten ...
Reviews hearing rights for appropriateness and submits them for processing to ensure compliance ... of either pediatric, Developmental Disabilities or mental health experience within the last ten ...
... Pediatrics patients, especially in mental health, is strongly preferred. The Social Worker will complete psychosocial assessments, utilization review with insurance companies, stabilize patients ...
New
... Pediatrics patients, especially in mental health, is strongly preferred. The Social Worker will complete psychosocial assessments, utilization review with insurance companies, stabilize patients ...
New
... Pediatrics patients, especially in mental health, is strongly preferred. The Social Worker will complete psychosocial assessments, utilization review with insurance companies, stabilize patients ...
New
... Pediatrics patients, especially in mental health, is strongly preferred. The Social Worker will complete psychosocial assessments, utilization review with insurance companies, stabilize patients ...
New
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?
| Aspect | Pediatric Utilization Review | Pediatric Case Manager |
|---|---|---|
| Credentials | Typically requires nursing or healthcare-related certifications | Requires nursing, social work, or healthcare certifications |
| Work Environment | Reviewing medical records and insurance claims, often remotely or in office | Direct patient interaction, coordinating care, often in clinical or community settings |
| Employer & Industry | Hospitals, insurance companies, healthcare organizations | Hospitals, 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 Ohio?
For Pediatric Utilization Review jobs in Ohio, the most frequently searched job titles are:
What job categories do people searching Pediatric Utilization Review jobs in Ohio look for?
The top searched job categories for Pediatric Utilization Review jobs in Ohio are:
What cities in Ohio are hiring for Pediatric Utilization Review jobs?
Cities in Ohio with the most Pediatric Utilization Review job openings:
Full-time
Re-posted 15 days ago
Nationwide Children's Hospital rating
6.9
Based on 131 frontline employees who took The Breakroom Quiz
545th of 1,065 rated hospitals
Job description
Overview:
Schedule: Monday-Friday (8:00am-4:30pm)
Position is work from home after a 90 day in-office training period.
Job Description Summary:
Reviews behavioral health cases to determine medical necessity and appropriateness of care, ensuring compliance with established guidelines and policies. Performs pre-certifications, pre-authorizations, re-authorization, concurrent utilization reviews, retrospective reviews, and denial management. Interacts with staff and departments of the hospital to facilitate appropriate, cost-effective patient care.
Job Description:
Essential Functions:
Education Requirement:
Bachelor's Degree in Social Work, Psychology, or related field, or equivalent education and experience, required
Licensure Requirement:
(not specified)
Certifications:
(not specified)
Skills:
Experience:
Physical Requirements:
OCCASIONALLY: Bend/twist, Climb stairs/ladder, Flexing/extending of neck, Lifting / Carrying: 0-10 lbs, Reaching above shoulder, Squat/kneel
FREQUENTLY: Standing, Walking
CONTINUOUSLY: Audible speech, Color vision, Computer skills, Decision Making, Depth perception, Hand use: grasping, gripping, turning, Hearing acuity, Interpreting Data, Peripheral vision, Problem solving, Repetitive hand/arm use, Seeing - Far/near, Sitting
Additional Physical Requirements performed but not listed above:
(not specified)
"The above list of duties is intended to describe the general nature and level of work performed by individuals assigned to this classification. It is not to be construed as an exhaustive list of duties performed by the individuals so classified, nor is it intended to limit or modify the right of any supervisor to assign, direct, and control the work of employees under their supervision. EOE M/F/Disability/Vet"
Schedule: Monday-Friday (8:00am-4:30pm)
Position is work from home after a 90 day in-office training period.
Job Description Summary:
Reviews behavioral health cases to determine medical necessity and appropriateness of care, ensuring compliance with established guidelines and policies. Performs pre-certifications, pre-authorizations, re-authorization, concurrent utilization reviews, retrospective reviews, and denial management. Interacts with staff and departments of the hospital to facilitate appropriate, cost-effective patient care.
Job Description:
Essential Functions:
- Conducts utilization reviews of behavioral health cases to determine medical necessity, appropriateness of care, and adherence to clinical guidelines.
- Communicates with healthcare teams and third-party payors to ensure the delivery of quality care and optimum payment.
- Assists with retrospective reviews and denial management to maintain appropriate and cost-effective patient care.
- Documents all case reviews and maintains accurate records of all clinical activities and coverage information.
- Provides education and support regarding utilization review and management activities and processes.
- Analyzes clinical data to identify trends and patterns that may impact patient care. Participates in quality improvement initiatives to enhance the overall delivery of behavioral health services.
- Facilitates reimbursement by communicating with payers, other staff, patients, and families concerning status of funding and required actions.
Education Requirement:
Bachelor's Degree in Social Work, Psychology, or related field, or equivalent education and experience, required
Licensure Requirement:
(not specified)
Certifications:
(not specified)
Skills:
- Excellent written and verbal communication and interpersonal skills.
- Excellent customer service and organizational skills.
- Working knowledge of CMS and other review agency standards.
- Proficient with software applications including CM, payer web applications, MITS, and others.
Experience:
- Three years of behavioral health experience, required.
- One year of experience in pediatric care or services, required.
- Utilization review or utilization management experience, preferred.
Physical Requirements:
OCCASIONALLY: Bend/twist, Climb stairs/ladder, Flexing/extending of neck, Lifting / Carrying: 0-10 lbs, Reaching above shoulder, Squat/kneel
FREQUENTLY: Standing, Walking
CONTINUOUSLY: Audible speech, Color vision, Computer skills, Decision Making, Depth perception, Hand use: grasping, gripping, turning, Hearing acuity, Interpreting Data, Peripheral vision, Problem solving, Repetitive hand/arm use, Seeing - Far/near, Sitting
Additional Physical Requirements performed but not listed above:
(not specified)
"The above list of duties is intended to describe the general nature and level of work performed by individuals assigned to this classification. It is not to be construed as an exhaustive list of duties performed by the individuals so classified, nor is it intended to limit or modify the right of any supervisor to assign, direct, and control the work of employees under their supervision. EOE M/F/Disability/Vet"
What Nationwide Children's Hospital employees say
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About Nationwide Children's Hospital
Sourced by ZipRecruiter
Nationwide Children's Hospital, established in 1894, is a leading pediatric healthcare system based in Columbus, Ohio, United States. They serve as a primary pediatric network, providing wellness, preventive, diagnostic, treatment, and rehabilitative care for infants, children, adolescents, and adults with congenital disease. Being the third-largest pediatric hospital in the nation, Nationwide Children's Hospital prides itself on its relentless commitment to children and their families, driven by their core values of respect, integrity, determination, empathy, and solidarity. The institution's comprehensive mission is to enhance the health of children by providing high-quality, family-centered care, conducting groundbreaking research, advocating for pediatric health, and training top healthcare professionals.
Industry
Hospitals
Company size
10,000+ Employees
Headquarters location
Columbus, OH, US
Year founded
1892