Pediatric Utilization Nurse: Care Coordination & Denials

Children's Hospital of Philadelphia; Philadelphia (Philadelphia County); On-site; USD 92,000 - 117,000; Full time

Job summary

Children's Hospital of Philadelphia (CHOP) seeks a skilled Utilization Management Nurse to coordinate complex clinical data, assess plans of care, and communicate with payers. This role supports acute care patients and advancing pediatric care at CHOP.

You will determine medical necessity, monitor admissions and discharge planning, and collaborate with case managers and physicians to align care with payer criteria. Strong communication and organizational abilities are essential.

Qualifications

• Excellent communication skills (required).
• Strong organizational and multitasking abilities.
• Knowledge of payer processes and admission criteria.
• Proficiency with Microsoft Office tools and healthcare systems.

Responsibilities

• Determines medical necessity and level of care using clinical information and criteria.
• Monitors accommodation codes, patient class, and admission type.
• Validates admission criteria with third-party payers and physicians.
• Updates discharge plans and notifies payers of discharge dates.
• Communicates with case managers and collaborates with providers for payer denials and appeals.

Skills

Communication

Organization

Interpersonal skills

Team collaboration

Microsoft Office

Problem solving

Payer processes

Education

Technical Diploma in Nursing

Bachelor's Degree in Nursing

Tools

Payer portal

Job description

Children's Hospital of Philadelphia (CHOP) seeks a skilled Utilization Management Nurse to coordinate complex clinical data, assess plans of care, and communicate with payers. This role supports acute care patients and advancing pediatric care at CHOP.

You will determine medical necessity, monitor admissions and discharge planning, and collaborate with case managers and physicians to align care with payer criteria. Strong communication and organizational abilities are essential.