Clinical Precertification Nurse

HMSA; Kapolei (HI); On-site; USD 85,000 - 110,000; Full time

Job summary

HMSA in Hawaii seeks a Nurse Reviewer to render precertification determinations using medical necessity criteria and established policies. You will assess whether services are covered, clinically appropriate, or require Medical Director review, and collaborate with providers to obtain information.

You will follow CMS, NCQA, HSAG requirements, document outcomes, handle urgent and non-urgent requests, review services from inpatient to genetic testing, and coordinate with integrated health

Responsibilities

• Render precertification determinations using medical necessity criteria and established policies.
• Determine whether a service is a covered benefit and medically appropriate, or requires Medical Director review.
• Call providers to obtain additional clinical information for complex reviews.
• Approve precertification requests based on clinical judgment and available documentation.
• Consult Medical Directors on requests not meeting criteria and offer alternative covered options.
• Refer quality issues to Integrated Health Management, Pharmacy Department or Benefits Integrity as appropriate.
• Evaluate suspended claims against medical records to assess necessity and appropriateness.
• Communicate with providers, members and internal MM staff about reviews and outcomes.
• Review services including Transplants, Air Ambulance, Chemotherapy, Clinical Trials, Genetic Testing, Cancer Treatments and more.
• Document case summaries and review outcomes to meet regulatory requirements.

Job description

HMSA in Hawaii seeks a Nurse Reviewer to render precertification determinations using medical necessity criteria and established policies. You will assess whether services are covered, clinically appropriate, or require Medical Director review, and collaborate with providers to obtain information.

You will follow CMS, NCQA, HSAG requirements, document outcomes, handle urgent and non-urgent requests, review services from inpatient to genetic testing, and coordinate with integrated health