Pediatric Utilization Review Specialist

CHOC; Town of Florida (NY); On-site; USD 40,000 - 68,000; Full time

Job summary

CHOC in Orange, California seeks an experienced Utilization Review Representative to assess inpatient and outpatient statuses and manage authorization requests with payors. You will collaborate with RN Care Managers and support data collection, insurance verification, and financial counseling, ensuring accuracy and quality of service.

The role requires LVN licensure in California, BLS and preferred case-management credentials, with a focus on pediatric care and patient advocacy.

Qualifications

• Graduate of an accredited Licensed Vocational Nursing program.
• Preferred: Graduation with a Bachelor’s Degree in nursing from an accredited University.
• Certification in Utilization Review and/or Case Management; CPN.

Responsibilities

• Responsible for utilization review of inpatient and outpatient statuses.
• Process daily authorization requests with payors for treatments, services, and supplies in collaboration with the RN Care Managers Inpatient and Outpatient.
• Assist in the completion of the RN Care Manager’s case load, promoting data collection, insurance verification, financial counseling and customer service.
• Ensure work processed is accurate and complete in all areas of responsibilities.

Skills

Communication

Conflict resolution

Insurance verification

Customer service

Data gathering

Healthcare knowledge

Education

Licensed Vocational Nurse – CA

BLS Certification

Bachelor’s degree in Nursing

Job description

CHOC in Orange, California seeks an experienced Utilization Review Representative to assess inpatient and outpatient statuses and manage authorization requests with payors. You will collaborate with RN Care Managers and support data collection, insurance verification, and financial counseling, ensuring accuracy and quality of service.

The role requires LVN licensure in California, BLS and preferred case-management credentials, with a focus on pediatric care and patient advocacy.