Pediatric Utilization Review Specialist

CHOC Children's; Orange, Northern (CA, KY); Hybrid; USD 41,000 - 67,000; Full time

Job summary

CHOC Children's in Orange, CA is seeking a Utilization Review Representative to review inpatient and outpatient statuses and process authorization requests with payors in collaboration with RN Care Managers. This role ensures accurate data, insurance verification, and effective customer service.

You will assist with case load, work under pressure with changing priorities, and bring strong communication skills and knowledge of pediatric care.

Qualifications

• Must have 2 years of acute or ambulatory care experience.
• Licensed Vocational Nurse in CA; BLS required.
• Preferred BSN and pediatric nursing experience.
• Certification in Utilization Review and/or Case Management; CPN preferred.

Responsibilities

• Perform utilization review for inpatient and outpatient statuses.
• Process internal and external authorization requests with payors.
• Assist RN Care Manager with caseload and data collection.
• Conduct insurance verification and financial counseling.

Skills

Pediatric care knowledge

Communication skills

Time management

Conflict resolution

MS Office

Education

Licensed Vocational Nurse license (CA)

Bachelor’s degree in nursing (BSN) preferred

Job description

CHOC Children's in Orange, CA is seeking a Utilization Review Representative to review inpatient and outpatient statuses and process authorization requests with payors in collaboration with RN Care Managers. This role ensures accurate data, insurance verification, and effective customer service.

You will assist with case load, work under pressure with changing priorities, and bring strong communication skills and knowledge of pediatric care.