Utilization Management Review Nurse - Temporary

AlohaCare; Honolulu (HI); On-site; USD 70,000 - 85,000; Full time

Benefits offered by this job

Low-cost medical insurance

Paid time-off

401k employer contribution

Referral bonus

Pretax transportation & parking

Job summary

AlohaCare in Hawaii is seeking a UM Review Nurse to conduct prior authorizations and concurrent reviews using our care management system and validation tools. You will collaborate with Medical Directors to implement policies aligned with MedQUEST, Medicare, and NCQA standards.

Join a team that values collaboration, efficiency, and compliant, patient-centered utilization management, ensuring timely access to appropriate care and maintaining high-quality provider communications.

Qualifications

• Licensed RN or LPN in Hawaii.
• Minimum 1 year UM experience or 2 years direct inpatient care.
• Ability to conduct training with audiovisual presentations.
• Strong time management and organizational skills.
• Minimum of 3 years inpatient clinical experience.
• URAC/NCQA and HEDIS exposure.

Responsibilities

• Review referrals, member eligibility, benefit coverage, and qualifications.
• Interface with Providers to discuss PA processes and access to care.
• Perform medical necessity reviews for authorizations.
• Process authorization decisions in the care management system.
• Coordinate with internal teams for complex cases and referrals.
• Enter encounter data to maintain accurate records.
• Adhere to regulatory guidelines and AC policies.

Skills

Training ability

Communication

Time management

Independent work

Multi-project coordination

Education

Hawaii nursing license (RN/LPN)

Tools

QNXT

Care management system

Proprietary screening tool

Historical databases

Job description

Are you ready for new challenges and new opportunities?

Join our team!

Current job opportunities are posted here as they become available.

Subscribe to our RSS feeds to receive instant updates as new positions become available.

AlohaCare’s leadership empowers and engages its employees by recognizing outstanding job performance and collaboration. We share organization-wide updates during quarterly All Staff meetings. We encourage participation in volunteer and educational opportunities. We put a high value on honesty, respect, and trust-building. We encourage open-door, two-way, and frequent communication.

AlohaCare’s comprehensive benefits package includes low-cost medical, dental, drug and vision insurance, paid time-off, 401k employer contribution, referral bonus and pretax transportation and parking program.

The Opportunity:

The primary responsibility of the UM Review Nurse is to conduct prior authorizations and concurrent reviews, using proprietary or online tools for medical necessity and documentation systems that integrate service requests, care management, and claims. The nurse will work collaboratively with the Medical Directors to implement medical policies and guidelines that are consistent with MedQUEST, Medicare, and NCQA requirements. The UM Review Nurse fosters a team culture of interdependency, efficient workflows, new learning, adaptability to change, critical thinking, compliance, and professional provider communication. Cost-effective member access to clinical or health services is paramount in the UM Review Nurse’s daily activities. By behavior and work style, the UM Review Nurse communicates, coordinates, and collaborates with other AlohaCare staff or external parties that result in outstanding utilization management of members and their providers.

Primary Duties and Responsibilities:

• Review referrals, member eligibility, benefit coverage, and member qualifications using AlohaCare’s criteria.
• Interface with Providers (physicians, DME, and other providers) to discuss issues and concerns with PA requests process and facilitate timely access to medically necessary health care services required by plan members.
• Perform medical necessity reviews for authorizations and retrospective requests and discuss possible denials with AlohaCare’s Medical Director.
• Process authorization decisions using AlohaCare’s care management system.
• Provide interdepartmental communication and referrals for members with Severe Mental Illness, Special Education Needs and Disabilities, Aid to Disabled Review Committee, and Case Management.
• Provide timely computer entry of encounter information/ data to maintain an accurate record of clinical reviews and the services authorized.
• Maintain the assigned workload within turnaround times in compliance with state and federal regulations.
• Concurrent reviews related to hospitalizations or post-acute care venues are completed with the intent to address appropriate levels of care and timely discharge planning.
• Perform concurrent clinical review via phone and by review of clinical documentation, to determine the appropriate length of a patient’s inpatient stay in accordance with all state and federal mandated regulations and AC policy and procedure.
• Participate in internal inpatient clinical rounds in collaboration with AlohaCare’s internal clinical teams and Medical Director to discuss the current admissions, discharges, and complex cases.
• Conduct a clinical review of claims, readmission and appeals and grievances in accordance with all state and federal mandated regulations and AC policy and procedure.
• Respond to telephone messages, e-mails, and other forms of communication in a timely and professional manner.
• Welcome and participates in education and training activities.
• Identifies opportunities to improve processes and communicates them to the Manager.
• Participate in team coverage and scheduling.
• Learn and develop experience in the use of AlohaCare’s information system, proprietary screening tool, care management system, QNXT and, as necessary, AlohaCare’s historical databases.
• All other duties assigned.
• Adhere to regulatory compliance and quality guidelines as well as AlohaCare policies and procedures.
• Responsible for maintaining AlohaCare’s confidential information in accordance with AlohaCare policies, and state and federal laws, rules, and regulations regarding confidentiality. Employees have access to AlohaCare.

Requirements:

• Licensed RN or LPN in the State of Hawaii.
• Minimum of 1 year of experience in Utilization Management or a minimum of 2 years of direct patient care experience in a hospital setting.
• Ability to conduct training with audiovisual presentations.
• Achieves results, builds trust, communicate effectively, customer and quality focused.
• Able to work independently with minimal supervision.
• Able to effectively work in a fast-paced and changing environment, manage multiple projects and priorities across multiple teams/projects and in a matrixed environment.
• Possesses excellent time management and organizational skills; is dependable, enthusiastic, self-starting, and self-motivated. Uses time effectively, reacts professionally under pressure.
• Minimum of 3 years of inpatient clinical experience.
• State regulatory experience.
• URAC/NCQA and HEDIS exposure.

Mental, Physical and Environmental Demands:

• May require prolonged sitting- up to 4 hours.
• Requires prolonged operation of a computer workstation, including the ability to type for extended periods of time on a keyboard during the scheduled workday.?

Salary Range: $70,000 – $85,000 annually

Temporary hire through December 15, 2026

AlohaCare is committed to providing equal employment opportunity to all applicants in accordance with sound practices and federal and state laws. Our policy prohibits discrimination and harassment because of race, color, religion, sex (including gender identity or expression), pregnancy, age, national origin, ancestry, marital status, arrest and court record, disability, genetic information, sexual orientation, domestic or sexual violence victim status, credit history, citizenship status, military/veteran status, or other characteristics protected under applicable state and federal laws, regulations, and/or executive orders.