Registered Nurse III, Utilization Review

US Lawns; Hilo (HI); Hybrid; USD 85,000 - 110,000; Full time

Benefits offered by this job

13 holidays

Vacation 21 days

Sick days 21

Medical plan

Dental plan

Vision plan

Assistance program

Retirement system

Student loan repayment

Job summary

Hilo Benioff Medical Center in the East Hawaii Region seeks a detail-oriented Registered Professional Nurse III to support Utilization Review and Appeals, evaluating medical necessity and ensuring compliant reimbursement.

You will conduct inpatient reviews, assist with denied-claim appeals, and collaborate with case managers, physicians, and payers to meet authorization requirements while upholding care quality and regulatory standards.

Qualifications

• Knowledge of utilization review, reimbursement processes, and insurance guidelines.
• Strong clinical assessment, analytical thinking, and problem-solving abilities.
• Ability to interpret medical records, identify gaps, and support appeals with evidence-based rationale.
• Effective communication and collaboration skills across multidisciplinary teams.
• Strong organizational skills and ability to manage multiple priorities in a fast-paced environment.

Responsibilities

• Perform utilization reviews for inpatient admissions and continued stays using nationally recognized criteria to determine medical necessity and appropriate level of care.
• Conduct concurrent and retrospective chart reviews to validate clinical documentation, treatment plans, and patient progress.
• Assist with appeals of denied claims by analyzing records, identifying discrepancies, and gathering supporting documentation to demonstrate medical necessity.
• Collaborate with case managers, physicians, Patient Financial Services, and external payers to ensure compliance with authorization and reimbursement requirements.
• Communicate effectively with interdisciplinary teams and external stakeholders to resolve issues related to level of care, coverage, and documentation.
• Serve as a resource for utilization review and appeals processes while maintaining compliance with hospital policies, accreditation standards, and confidentiality requirements.

Skills

Utilization review

Clinical assessment

Medical record review

Communication

Organization

Education

BSN preferred

Job description

Job Description

Join Hilo Benioff Medical Center and be part of a team that proudly cares for our friends, family, and neighbors across East Hawai\u012b.

Hilo Benioff Medical Center, part of the East Hawaii Region of Hawaii Health Systems Corporation, is seeking a detail-oriented Registered Professional Nurse III to support our Utilization Review and Appeals functions. This role is responsible for evaluating the medical necessity and appropriateness of patient care while assisting with appeals to secure reimbursement and ensure compliance with regulatory and payer requirements. The ideal candidate will combine strong clinical knowledge with analytical and communication skills to support both patient care quality and organizational financial performance.

Key Responsibilities:

• Perform utilization reviews for inpatient admissions and continued stays using nationally recognized criteria to determine medical necessity and appropriate level of care.
• Conduct concurrent and retrospective chart reviews to validate clinical documentation, treatment plans, and patient progress.
• Assist with appeals of denied claims by analyzing records, identifying discrepancies, and gathering supporting documentation to demonstrate medical necessity.
• Collaborate with case managers, physicians, Patient Financial Services, and external payers to ensure compliance with authorization and reimbursement requirements.
• Communicate effectively with interdisciplinary teams and external stakeholders to resolve issues related to level of care, coverage, and documentation.
• Serve as a resource for utilization review and appeals processes while maintaining compliance with hospital policies, accreditation standards, and confidentiality requirements.

Minimum Qualifications:

• Education: Graduate of an accredited school of nursing (Bachelor’s Degree in Nursing preferred).
• Experience: Minimum of six (6) months of professional nursing experience.
• Certification: Basic Life Support (BLS) certification required within one (1) month of hire; Utilization Review certification preferred.
• Licensure: Current, valid Registered Nurse (RN) license in the State of Hawai\u012b.

Preferred Skills & Attributes:

• Knowledge of utilization review, reimbursement processes, and insurance guidelines.
• Strong clinical assessment, analytical thinking, and problem-solving abilities.
• Ability to interpret medical records, identify gaps, and support appeals with evidence-based rationale.
• Effective communication and collaboration skills across multidisciplinary teams.
• Strong organizational skills and ability to manage multiple priorities in a fast-paced environment.

Join a dedicated healthcare team committed to delivering high-quality care while supporting efficient and effective utilization of healthcare resources for our island community.

Company Description

As the Big Island\u2019s leading providers of inpatient and outpatient care, the East Hawaii Region of Hawai\u2018i Health Systems Corporation (HHSC), consisting of Hilo Benioff Medical Center, Honoka\u2019a Hospital, Ka\u2019u Hospital, Yukio Okutsu State Veterans Home, East Hawaii Medical Group and East Hawaii Health Pharmacy, delivers a full range of services and programs. Our three hospitals include 290 beds and more than 1,900 employees. Our medical staff is comprised of 250 physicians, physician assistants and Advanced Practice Registered Nurses, representing 33 specialties. East Hawaii Health is our network of clinics offering primary and specialty care. Hilo Benioff Medical Center functions as a Level III Trauma Center, which includes the second busiest emergency room in the state, providing 24-hour care and serving more than 50,000 patients annually. Honoka\u2019a Hospital and Ka\u2019u Hospital are designated as Critical Access Hospitals. To learn more about the East Hawaii Region, please watch our Video Yearbook or visit www.hbmc.org, www.honokaahospital.org or www.kauhospital.org.

Benefits

• 13 paid holidays each year (104 hours); 14 (112 hours) during election years*
• 21 paid vacation days (168 hours) per year*
• 21 paid sick days (168 hours) per year*
• Medical, dental, vision, and prescription plans
• Employee Assistance Program
• Participation in the State of Hawaii\u2019s retirement system
• Potential eligibility for various student loan repayment & scholarship programs

* Rates listed for paid holidays, vacation and sick days are for 1.0 Full Time Equivalent (FTE) positions assigned to 8 hour shifts. Accruals for these benefits are otherwise prorated based on FTE.

Pre-Employment Health Requirements

Offers of employment will be contingent on successfully passing a pre-employment examination, which includes a drug screen and other regulatory medical requirements such as, but not limited to, a tuberculosis (TB) screen. The cost for drug screening and blood draw for QuantiFERON and Titers, shall be borne by the Hawaii Health Systems Corporation.

Pre-Employment Assessments for External Candidates

As part of the recruiting process for this position, external applicants (job applicants NOTemployed byHHSC\u2019s East Hawaii Region)are required to complete pre-employment assessments shortly after application submission. If you are notan employee of the East Hawaii Region of HHSC, youwill receive an email containing assessment instructions. We ask that you complete the assessments within two days of receipt of the request.

Equal Opportunity Employer

The East Hawaii Region of Hawaii Health Systems Corporation is a drug free workplace and an Equal Opportunity Employer.

Shift Details

Must be available to work shifts, weekends and holidays as necessary based on hospital operations. Services are provided 24/7.