Director, Clinical Review & Utilization Strategy (Hybrid)

HMSA; Honolulu (HI); Hybrid; USD 150,000 - 230,000; Full time

Job summary

HMSA in Hawaii seeks an executive to lead Clinical Review operations, including prior authorization, prospective and concurrent reviews, and facility reviews. You will align workflows, staffing, and decision-making with enterprise objectives and affordability goals.

Responsibilities include ensuring regulatory compliance, accreditation readiness, and ongoing quality oversight. You will drive performance, supervise a multi-level team, and manage vendor relationships to meet contractual and

Qualifications

• Leadership experience in clinical operations or utilization management.
• Knowledge of CMS, NCQA, Hawaii Medicaid and Medicare Advantage program requirements preferred.
• Strong analytical skills and ability to lead large teams.

Responsibilities

• Provide strategic and operational leadership for Clinical Review functions including Prior Authorization, Prospective, Concurrent, facility review, inpatient and outpatient settings.
• Ensure regulatory compliance, accreditation readiness, and quality oversight for Clinical Review.
• Drive program evaluation, performance improvement, and affordability outcomes using data analytics and dashboards.
• Lead a multi-level clinical review organization with coaching and development for staff.
• Oversee vendor management and cross-functional collaboration with delegated partners and internal stakeholders.

Job description

HMSA in Hawaii seeks an executive to lead Clinical Review operations, including prior authorization, prospective and concurrent reviews, and facility reviews. You will align workflows, staffing, and decision-making with enterprise objectives and affordability goals.

Responsibilities include ensuring regulatory compliance, accreditation readiness, and ongoing quality oversight. You will drive performance, supervise a multi-level team, and manage vendor relationships to meet contractual and