Concurrent Care Utilization Review Nurse

hmsacareers; Honolulu (HI); On-site; USD 85,000 - 110,000; Full time

Job summary

HMSA Careers in Hawaii seeks a Nurse Reviewer to apply medical necessity criteria and perform concurrent review determinations in alignment with UM policies and accrediting requirements. You will evaluate inpatient stays, coordinate with Medical Directors, and support case management to optimize care and costs.

The role requires an active Hawaii RN or LPN license, strong clinical judgment, and the ability to communicate with providers and internal teams to ensure appropriate levels of care and

Qualifications

• Associates Degree in Nursing.
• Two years clinical care experience or case management.
• Knowledge of the appropriate protocol to be followed for a given diagnosis and the normative values of medical tests and procedures.
• Typing speed of 40 wpm.
• Strong organizational skills.
• Good communication skills: verbal and written.
• Basic working knowledge of Microsoft Office applications (Word, Excel, Outlook).
• Hawaii RN or LPN license required; proof of licensure to be provided upon hire.

Responsibilities

• Applies medical necessity criteria from established policies to concurrent review determinations.
• Determines inpatient hospital stays as medically appropriate or refers to Medical Director for potential denial.
• Follow CMS, NCQA, HSAG requirements for inpatient admissions.
• Coordinate with case management staff, providers, and departments to improve quality of care and control costs.
• Identify cost savings and document all communications and interventions.
• Refer members to Case Management or QUEST Integration as appropriate.
• Identify and refer members with complex needs or potential fraud, waste, or abuse as needed.

Skills

Typing 40 wpm

Strong organizational skills

Good communication skills

Microsoft Office

Education

Associates Degree in Nursing

Job description

HMSA Careers in Hawaii seeks a Nurse Reviewer to apply medical necessity criteria and perform concurrent review determinations in alignment with UM policies and accrediting requirements. You will evaluate inpatient stays, coordinate with Medical Directors, and support case management to optimize care and costs.

The role requires an active Hawaii RN or LPN license, strong clinical judgment, and the ability to communicate with providers and internal teams to ensure appropriate levels of care and