Manager, Clinical Review

hmsacareers; Honolulu (HI); On-site; USD 120,000 - 150,000; Full time

Job summary

HMSA seeks an experienced nursing leader to manage multiple units across locations, driving teamwork and staff development. You will guide teams to align with HMSA strategies, ensure timely preauthorization activities, and support compliance with NCQA, DOL, and internal policies.

The role oversees LTSS/CIS/EVV programs, acts as a subject matter expert, and collaborates on new workflows and initiatives, while mentoring staff to meet organizational goals.

Qualifications

• Bachelor's degree or equivalent combination of education and related work experience.
• Two years of supervisory, management or leadership experience.
• Current Hawaii RN license and three years of clinical experience.
• Experience training staff and developing workflows.
• Experience working in the healthcare industry and knowledge of utilization management.
• Knowledge of CPT-4, HCPCS, ICD-10 and UB-04/HCFA 1500 forms.
• Proficiency with Microsoft Word, Excel, Outlook and PowerPoint.

Responsibilities

• Lead and manage multiple units/teams across locations, fostering teamwork and growth.
• Ensure timely, compliant preauthorization activities per HMSA, NCQA, and DOL standards.
• Oversee LTSS, CIS, EVV programs and related compliance.
• Serve as SME for MM, guiding committees and projects.
• Collaborate with partners to implement new programs, workflows, and policies.
• Recruit, coach, and mentor staff to achieve department goals.

Skills

Leadership

Supervisory experience

Staff training

Healthcare utilization management

Workflows development

Education

Bachelor's degree

Registered Nurse (RN) license

Tools

Microsoft Office

Job description

Job Responsibilities

1. Management of multiple units/teams and staff in multiple locations, fostering a work environment that encourages teamwork, promotes personal growth and learning.
   • Provide leadership and direction to align with HMSA strategic initiatives and mission, as well as best practices in the industry.
   • Provide leadership, direction and support to the teams to ensure compliance with HMSA, NCQA and DOL standards governing the timeliness and quality of preauthorization activities.
   • Oversee compliance with legal and contractual standards related to precertification, payment determinations and concurrent reviews so that cases are reviewed timely and in accordance with HMSA's policies and benefits and accreditation standards.
2. Management of the multi-department QUEST Integration programs associated with Long-Term Services Support (LTSS), Community Integration Services (CIS) and Electronic Visit Verification (EVV).
3. Serve as a subject matter expert for MM, leading and/or participating in internal committees, workgroups and projects. Such groups may be focused on problem resolution, program updates or implementation of new programs and initiatives that support compliance and/or HMSA goals.
4. Oversees and collaborate with internal and external partners in the development and implementation of new or updated programs, workflows, policies & procedures system solutions to support the objectives of the respective team(s).
5. Hires, develops, coach and mentor staff to effectively meet corporate and department goals / objectives associated with management of the benefit cost trend through the implementation of utilization management activities.
   • Assess, identify and manage the appropriate resources needed to effectively meet HMSA Center business goals (budget, staff, support, coaching, etc.).
   • Allocate and re-allocate the appropriate resources based on workload and/or changing business needs.
6. Collaborate on a regular basis with departmental management teams to develop, implement and create coordination among all workflows and processes among multiple internal teams.
7. Research and resolve, complex and/or high-level member and provider inquiries.
8. Perform special projects as assigned.

Requirements

1. Bachelor's degree and five years of related work experience; or an equivalent combination of education and related work experience.
2. Two years of supervisory, management or leadership experience.
3. Current Nursing License in the state of Hawaii as a Registered Nurse and three (3) years clinical experience
4. Experience training staff.
5. Experience developing workflows and training materials.
6. Experience working in the healthcare industry
7. Knowledge of Healthcare Utilization Management programs
8. Some knowledge of CPT-4, HCPCS, ICD-10 and other claims coding systems, and UB-04 and HCFA 1500 forms.
9. Basic working knowledge of Microsoft Office applications. Including but not limited to Word, Excel, Outlook and Power Point.
10. Registered Nurse (RN) in the state of Hawaii.