[Hiring] Utilization Management RN – Pediatrics @Morgan Stephens

Role Description

The Utilization Management RN – Pediatrics plays a critical role in ensuring pediatric healthcare services are delivered with quality, cost efficiency, and full regulatory compliance. Through clinical review and coordination, this role supports appropriate levels of care, medical necessity determinations, and positive outcomes for pediatric patients and families. This position is ideal for an RN with pediatric clinical experience and a strong background in utilization review, prior authorization, case management, or managed care.

Job Duties and Responsibilities

• Perform concurrent review of pediatric clinical cases for medical necessity and appropriateness of care
• Conduct review of prior authorization and precertification requests for pediatric services and treatments
• Ensure services align with established clinical guidelines including MCG or InterQual criteria
• Collaborate with providers, care teams, and health plan representatives to support coordinated care planning
• Monitor utilization trends and identify opportunities to improve quality and cost efficiency
• Assist with discharge planning and transition of care coordination for pediatric populations
• Advocate for quality patient outcomes and timely access to medically necessary services
• Maintain accurate and timely clinical documentation within EMR and utilization management systems
• Prepare reports related to utilization activity, case outcomes, and authorization trends
• Work independently in a fast-paced remote environment while maintaining productivity and quality standards

Qualifications

• Active, unrestricted Registered Nurse (RN) license in New York required
• Minimum of 2+ years of pediatric nursing experience required
• Minimum of 2+ years of Utilization Management, Case Management, or Prior Authorization experience preferred
• Strong knowledge of MCG or InterQual guidelines
• Experience with medical necessity review, concurrent review, and utilization management workflows
• Proficiency with EMR systems and Microsoft Office (Excel, Word, Outlook)
• Strong communication, critical thinking, and organizational skills
• Ability to work independently in a fully remote environment

Preferred Experience

• Pediatric managed care or pediatric hospital experience
• Medicaid or commercial pediatric population experience
• Experience working with children with complex medical needs or chronic conditions
• UM or Case Management certification (CCM, ACM) preferred

Why This Role Matters

This role directly supports improved healthcare outcomes for pediatric patients by ensuring medically appropriate, timely, and cost-effective care. You will help families navigate healthcare services while supporting quality-driven clinical decision-making.