Manager, Clinical Review

Socket.dev; Honolulu (HI); Hybrid; USD 90,000 - 130,000; Full time

Job summary

HMSA in Hawaii seeks an experienced Nursing Leader to manage multiple units across locations, providing leadership and alignment with strategic initiatives. The role ensures compliance with HMSA, NCQA and DOL standards for preauthorization activities and oversees LTSS, CIS and EVV programs.

The ideal candidate holds an RN license in Hawaii with 2+ years of supervisory experience and a proven ability to train staff, develop workflows and collaborate with partners across the healthcare landscape.

Qualifications

• Bachelor's degree or equivalent combination of education and related work experience.
• Two years of supervisory, management or leadership experience.
• Current Nursing License in the state of Hawaii as a Registered Nurse and three (3) years clinical experience.
• Experience training staff.
• Experience developing workflows and training materials.
• Experience working in the healthcare industry
• Knowledge of Healthcare Utilization Management programs
• Some knowledge of CPT-4, HCPCS, ICD-10 and other claims coding systems, and UB-04 and HCFA 1500 forms.
• Basic working knowledge of Microsoft Office applications, including Word, Excel, Outlook and PowerPoint.

Responsibilities

• Management of multiple units/teams across locations, fostering teamwork and personal growth.
• Provide leadership and direction to align with HMSA strategic initiatives and best industry practices.
• Ensure compliance with HMSA, NCQA and DOL standards for timeliness and quality of preauthorization activities.
• Oversee QUEST Integration programs for LTSS, CIS and EVV.
• Serve as a subject matter expert for MM and participate in committees and projects.
• Collaborate with internal and external partners on programs, workflows and policies.
• Hire, develop, coach and mentor staff to meet goals via utilization management activities.
• Assess resources and allocate accordingly to meet HMSA Center business goals.
• Engage with management to coordinate workflows and resolve complex inquiries.
• Perform special projects as assigned.

Skills

Nursing License (RN)

Supervisory / leadership

Training staff

Workflow development

Healthcare industry experience

CPT-4 / HCPCS / ICD-10 knowledge

UB-04 / HCFA 1500 forms knowledge

MS Office (Word, Excel, Outlook, Power

Education

Bachelor's degree

Five years related work experience

Job description

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.

LI-HybridQualifications

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.