UM Review Nurse: Impactful Care & Compliance

Alohacare; Honolulu (HI); Hybrid; USD 70,000 - 85,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

Paid time off

401k matching

Referral bonus

Transit benefits

Job summary

AlohaCare in Hawaii is seeking a UM Review Nurse to conduct prior authorizations and concurrent reviews, using proprietary and online tools to evaluate medical necessity and documentation that integrates service requests, care management, and claims.

The role emphasizes collaboration with Medical Directors to implement policies compliant with MedQUEST, Medicare, NCQA, and state regulations, focusing on efficient workflows and high-quality provider communication.

Qualifications

• Licensed RN or LPN in Hawaii.
• Minimum 1 year of Utilization Management experience or 2 years direct patient care in hospital.
• Ability to conduct trainings with audiovisuals.
• Strong communication, customer focus and quality orientation.
• Independent work capability with minimal supervision.
• Ability to thrive in fast-paced, changing environments with multiple priorities.
• Minimum 3 years inpatient clinical experience.
• State regulatory experience; URAC/NCQA and HEDIS exposure.

Responsibilities

• Review referrals, member eligibility, and benefits using AlohaCare criteria.
• Interface with Providers to discuss PA requests and ensure timely access to services.
• Perform medical necessity reviews for authorizations and retrospective requests.
• Process authorization decisions in the care management system.
• Provide interdepartmental communication for complex cases.
• Enter encounter data to maintain accurate records of reviews and actions.
• Maintain workload within required turnaround times.
• Complete concurrent reviews related to hospitalizations and post-acute care.
• Participate in rounds with Medical Director and clinical teams.

Skills

RN/LPN license Hawaii

Utilization management

Inpatient hospital exp

Training/presentation

Time management

Communication

Autonomy

Education

Licensed RN or LPN in Hawaii

Minimum 3 years inpatient clinical experience

Job description

AlohaCare in Hawaii is seeking a UM Review Nurse to conduct prior authorizations and concurrent reviews, using proprietary and online tools to evaluate medical necessity and documentation that integrates service requests, care management, and claims.

The role emphasizes collaboration with Medical Directors to implement policies compliant with MedQUEST, Medicare, NCQA, and state regulations, focusing on efficient workflows and high-quality provider communication.