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Pediatric Utilization Review Jobs in Utah (NOW HIRING)

Imh

Pediatric Physical Therapist

Layton, UT

$43.09 - $66.47/hr

Participates in utilization review audits. * Meetings : Participates in patient care conferences, interdisciplinary meetings, staff meetings, and necessary professional and work groups in ...

Imh

$43.09 - $66.47/hr

Participates in utilization review audits. * Meetings : Participates in patient care conferences, interdisciplinary meetings, staff meetings, and necessary professional and work groups in ...

CVS Health

Case Manager, Registered Nurse

Mountain Home, UT · On-site

$54K - $155K/yr

... Pediatrics, Medical/Surgical, Behavioral Health/Substance Abuse or Maternity/ Obstetrics experience ... Utilization Review. * CCM and/or other URAC recognized accreditation preferred. * 1+ years ...

HOME CAREGIVERS PARTNERSHIP LLC

RN

Salt Lake City, UT · On-site

... pediatric patients on weekends for 8-12 hour day and Night shifts. Training available for new or ... Participates in utilization review of medical records as assigned. * Gives total patient care as ...

HOME CAREGIVERS PARTNERSHIP LLC

RN

Springville, UT · On-site

... pediatric patients on weekends for 8-12 hour day and Night shifts. Training available for new or ... 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 Utah?

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

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

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

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

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

Pediatric Utilization Review jobs near you
Infographic showing various Pediatric Utilization Review job openings in Utah as of August 2026, with employment types broken down into 1% As Needed, 76% Full Time, 20% Part Time, 2% Contract, and 1% Nights. Highlights an 89% Physical, 3% Hybrid, and 8% Remote job distribution.

Medical Director - Utilization Management/Care Management, Select Health

Intermountain Health

Murray, UT • On-site

$332K - $377K/yr

Full-time

Re-posted 3 days ago

Intermountain Health rating

7.2

Company rating: 7.2 out of 10

Based on 846 frontline employees who took The Breakroom Quiz

344th of 895 rated healthcare providers

Job description

Job Description:
Select Health, a regional health plan with over a million members serving all lines of business in Utah, Idaho, Nevada and Colorado, is seeking an experienced Medical Director with expertise in Utilization Management (UM), Care Management (CM) and Health Plan accreditation and other operational and regulatory functions.
The Medical Director of Utilization Management/Care Management, reporting directly to the Chief Medical Officer, leads the UM and CM functions for Select Health from a clinical perspective, ensuring that care services are high quality, appropriate, efficient and in compliance with regulatory and accreditation standards. The role combines oversight of the UM and CM functions with Select Health strategies to ensure members receive coverage and services for high-quality, appropriate, efficient, and cost-effective care.
Essential Functions
  • Key Responsibilities
    • Strategic Leadership: Develop and implement UM and CM strategies using data analytics, technology, and cost-benefit analysis to optimize covered services and care management efforts.

    • Policy & Process Development: Participate in the creation, revision and enforcement of UM/CM policies, procedures, and protocols to meet regulatory and other accreditation requirements .

    • Operational Oversight: From a clinical perspective, manage provider reviewers, concurrent reviews, prior authorizations, medical claims reviews, appeals, and grievances and ensure timely and accurate service authorizations consistent with regulatory and accreditation standards .

    • Efficiency & Innovation: Identify process improvements, redesign workflows, and implement processes including auto-approvals , alternative site criteria evaluation , artificial intelligence solutions and prior auth orization efficiency where appropriate to reduce administrative burden.

    • Pro- Active Care (Value-based Care): Participate in system innovation opportunities such as risk-based contracting, appropriate reduction of prior authorization or other identified opportunities to affect administrative simplification and reduce abrasion for members and providers.

    • Data & Trend Analysis: Monitor utilization trends, measure productivity metrics, and report on cost savings and quality outcomes across areas of responsibility .

    • Provider & Vendor Management: Build and maintain strong relationships with such Select Health required vendors and clinical teams necessary to improve care quality and efficiency.

    • Compliance & Quality: Ensure adherence to state/federal regulations, accreditation standards, and contractual obligations; conduct provider education and training as necessary to facilitate compliance and adherence to quality measures .

    • Team Leadership: Supervise and mentor UM/CM staff, provide executive-level guidance, and support workforce planning as needed .

    • Special Projects: Lead initiatives to improve member/provider experience, reduce unnecessary services, and enhance clinical decision support.

Skills
  • Leadership
  • Communication
  • Taking Initiative
  • Performance management
  • Process Improvements
  • Teamwork
  • Workflow optimization
  • Process documentation
  • Health plan operation
  • Federal, state and local regulations
  • Computer Literacy

Additional Details
  • FTE: 1.0
  • Salary: $332,300 - 377,400 based on relevant experience
  • Eligible for an annual leadership incentive opportunity based on system goals
  • In addition to the annual salary, to show our commitment to you and assist with your transition, we may offer a sign-on and relocation bonus when applicable.

Minimum Qualifications
  • Medical Doctor or Doctor of Osteopathic Medicine degree with Board Certification in one of the following areas: Internal Medicine, Pediatrics, Family Practice, Psychiatry or Emergency Medicine.
  • Requires current MD or DO licensure within the State of Utah, Idaho, Nevada or Colorado
  • Five years of experience in clinical practice.

Preferred Qualifications
  • Utilization management, care management and/or experience in policy related work for a health plan or managed care organization.
  • Previous management experience.
  • Experience with financial and medical expense management.
  • Understanding of health care delivery system as it relates to government programs and agencies.
  • Excellent communication skills including ability to establish and maintain rapport with coworkers, providers, brokers, employers, plan members, representatives/executives from other health care entities, government and regulatory bodies and others in the community.

Physical Requirements
  • Ongoing need for employees to see and read information, documents, monitors, identify equipment and supplies, and be able to assess member, provider, and coworkers' needs.
  • Frequent interactions with colleagues and providers require employees to verbally communicate as well as hear and understand spoken information, needs, and issues quickly and accurately.
  • Frequent computer use for typing, accessing needed information, etc.

Location:
SelectHealth - Murray
Work City:
Murray
Work State:
Utah
Scheduled Weekly Hours:
40
The hourly range for this position is listed below. Actual hourly rate dependent upon experience.
$70.00 - $999.99
We care about your well-being - mind, body, and spirit - which is why we provide our caregivers a generous benefits package that covers a wide range of programs to foster a sustainable culture of wellness that encompasses living healthy, happy, secure, connected, and engaged.
Learn more about our comprehensive benefits package here .
By applying for a position with Intermountain, I acknowledge that I will comply with all applicable Intermountain policies and expectations. If applying for a remote or hybrid role, this includes remote work expectations related to confidentiality, information security, work schedules, conflicts of interest, and use of company equipment. I further acknowledge that outside employment or activities may not interfere with job responsibilities or create a conflict of interest with Intermountain. Actual or reasonably perceived conflicts may be grounds for disqualification from consideration or, if hired, corrective action up to and including termination of employment.
Intermountain Health is an equal opportunity employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.
At Intermountain Health, we use the artificial intelligence ("AI") platform, HiredScore to improve your job application experience. HiredScore helps match your skills and experiences to the best jobs for you. While HiredScore assists in reviewing applications, all final decisions are made by Intermountain personnel to ensure fairness. We protect your privacy and follow strict data protection rules. Your information is safe and used only for recruitment. Thank you for considering a career with us and experiencing our AI-enhanced recruitment process.
All positions subject to close without notice.

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