The Utilization Management (UM) Physician Reviewer at Cincinnati Children’s ensures that pediatric Medicaid members receive medically necessary, evidence-based, and cost-effective care. Working within Cincinnati Children’s Healthvine, an Accountable Care Organization (ACO) seated within the Office of Population Health at Cincinnati Children’s Hospital, this role supports care quality, utilization efficiency, and compliance with Medicaid regulations. The position involves clinical review, interdisciplinary collaboration, and strategic input into population health initiatives.

Position Highlights

• Remote work (full-time or half-time) available in multiple states*
• Schedule: Monday–Friday, 8:00am–5:00pm EST; minimal weekend/holiday on-call
• Collaborative environment supporting care quality and compliance

*Telecommuting on a full-time basis may be permitted in the following states:

AL, AZ, AR, FL, GA, ID, IN, IA, KS, KY, LA, MI, MS, MO, NC, OH, OK, SC, SD, TN, TX, UT, VA, WV, WY.

Key Responsibilities

• Conduct prospective, concurrent, and retrospective reviews of medical services for pediatric Medicaid members.
• Apply clinical guidelines and Medicaid-specific criteria to assess medical necessity
• Participate in peer-to-peer discussions with treating providers to clarify clinical information and support appropriate care decisions.
• Collaborate with RN Specialists, Senior RN Specialist and Clinical Director to support integrated care planning.
• Provide clinical input on complex cases involving social determinants of health, chronic conditions, or developmental disabilities.
• Support transitions of care, especially from inpatient to outpatient settings, to reduce readmissions.
• Ensure adherence to federal and state Medicaid regulations, NCQA standards, and ACO performance metrics.
• Participate in - Participates in interrater reliability audit process, quality improvement initiatives, and utilization trend analysis.
• Contribute to the development of clinical policies, pathways, and educational materials for providers.
• Advise on utilization trends and opportunities for cost containment and care optimization.
• Support the implementation of value-based care initiatives and pediatric population health strategies.
• Serve as a subject matter expert in pediatric care for internal and external stakeholders.

Qualifications and Experience

• MD or DO from an accredited medical school
• Board Certification in Pediatrics (ABP) required; subspecialty certification (e.g., Pediatric Emergency Medicine, Pediatric Hospital Medicine) preferred.
• Active, unrestricted Ohio medical license
• Certified in Utilization Management (or willing to obtain within 12 months)
• Basic Life Support (BLS) certification (if clinically active)
• Familiarity with HIPAA, NCQA, and CMS guidelines
• 3–5 years clinical experience (pediatric focus preferred)
• 1–2 years in utilization management, managed care, or ACO settings preferred
• Experience with Medicaid populations and pediatric health disparities highly desirable
• Proficiency with Epic, MCG, and UM platforms

Ready to make an impact?

Send your letter of interest and CV to Julia Sweet julia.sweet@cchmc.org, Senior Talent Acquisition Specialist.

Cincinnati Children’s is proud to be an Equal Opportunity Employer committed to creating an environment of dignity and respect for all our employees, patients, and families. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, genetic information, national origin, sexual orientation, gender identity, disability or protected veteran status. 

About Cincinnati Children's

Cincinnati Children's is a nonprofit, comprehensive pediatric health system. As the leader in research and education, Cincinnati Children’s is consistently ranked as one of America's best children's hospitals by U.S. News & World Report and is one of the top recipients of pediatric research grants from the National Institutes of Health.

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