Clinical Utilization & Authorization Specialist I

HMSA; Kapolei (HI); Hybrid; USD 70,000 - 90,000; Full time

Job summary

HMSA is seeking a detail‑oriented professional to evaluate and process clinical review requests, educate providers, and apply regulatory requirements. The role includes multi‑system eligibility checks, UM documentation, and managing authorization workflows to influence claims processing.

You will handle online authorizations, address issues with supervisors, and support inquiries from providers and members using a structured call strategy. Hybrid work supported.

Responsibilities

• Evaluate, interpret, and process clinical review requests ensuring submission requirements meet accreditation/governmental regulation requirements.
• Educate provider offices on appropriate procedures.
• Apply internal policies, contractual provisions, and regulatory requirements.
• Multi-system validation of member-specific eligibility, benefit and provider requirements for services based on member's primary line of business.
• Utilize resources to confirm HMSA's clinical review requirements and respond with outcomes.
• Create the electronic file within the UM management system for review.
• Adhere to guidelines for document management within the Fax Manager Application.
• Process vendor authorization files to reflect decisions impacting claims processing and update authorizations as needed.
• Notify or communicate issues with authorization files to the unit coordinator, supervisor or UM Solutions Administrator.
• Respond to inquiries from providers/members using Ulysses Call Strategy; research resources; triage and transfer calls; escalate as needed.
• Process Aerial to QNXT (A2Q) error/balance reports; build UM documents in QNXT to support claims processing.
• Monitor and process clinical review requests received via online authorization tool; apply policies and validate eligibility; triage distribution.

Job description

HMSA is seeking a detail‑oriented professional to evaluate and process clinical review requests, educate providers, and apply regulatory requirements. The role includes multi‑system eligibility checks, UM documentation, and managing authorization workflows to influence claims processing.

You will handle online authorizations, address issues with supervisors, and support inquiries from providers and members using a structured call strategy. Hybrid work supported.