Oahu Hybrid Director, Clinical Review & Utilization

Hawaii Medical Service Association; Honolulu (HI); Hybrid; USD 115,000 - 238,000; Full time

Job summary

Hawaii Medical Service Association (HMSA) seeks a Director of Clinical Review to lead utilization management and prior authorization activities across Commercial, Medicare, Medicaid, and other programs. You will drive strategy, oversight, and continuous improvement to ensure clinically appropriate, timely, and cost-effective review decisions.

You will partner with Medical Directors, Compliance, Quality, Finance, and delegated vendors to improve turnaround times, documentation quality, and audit

Qualifications

• Bachelor's degree in Nursing.
• RN license: Hawaii license required or obtainable on hire.
• 7+ years healthcare leadership experience, with at least 5 years in UM/managed care.
• Experience leading clinical review functions including Prior Authorization, Prospective, and Concurrent Review.

Responsibilities

• Provide strategic and operational leadership for Clinical Review operations and utilization management activities across programs.
• Oversee budgeting, workforce planning, staffing, and financial stewardship to meet goals.
• Ensure regulatory compliance, accreditation readiness, and quality oversight of Clinical Review.
• Lead program evaluation using data analytics and performance reporting to drive improvements.
• Manage vendor oversight and cross-functional collaboration with internal and external partners.

Skills

Nursing leadership

Regulatory knowledge

Data analysis

Communication skills

Project management

Strategic planning

Education

Bachelor's degree in Nursing

Tools

Word

Excel

PowerPoint

Outlook

Job description

Hawaii Medical Service Association (HMSA) seeks a Director of Clinical Review to lead utilization management and prior authorization activities across Commercial, Medicare, Medicaid, and other programs. You will drive strategy, oversight, and continuous improvement to ensure clinically appropriate, timely, and cost-effective review decisions.

You will partner with Medical Directors, Compliance, Quality, Finance, and delegated vendors to improve turnaround times, documentation quality, and audit