Director, Clinical Review

Hawaii Medical Service Association•Honolulu, HI

About The Position

The Director, Clinical Review provides strategic and operational leadership for Clinical Review operations, including prior authorization, prospective and concurrent review, facility review, inpatient and observation review, skilled nursing facility review, out-of-state review, and other utilization review activities. The role develops and executes strategic plans aligned with HMSA’s enterprise objectives, regulatory requirements, and affordability initiatives; establishes consistent workflows, staffing models, performance expectations, and clinical review decision-making processes; and manages departmental budgeting, workforce forecasting, staffing strategy, and resource allocation. It ensures clinical resources are aligned to top-of-license work and that operations are timely, accurate, member-centered, and scalable. The Director oversees complex utilization review cases, high-cost claim reviews, high-needs member populations, and multidisciplinary review processes in collaboration with Medical Directors and enterprise partners. The role is accountable for turnaround time, quality, productivity, service, and departmental performance goals, and leads regulatory compliance, accreditation readiness, and quality oversight. This includes keeping current with applicable federal, state, contractual, accreditation, and HMSA requirements; partnering with Compliance, Quality, Audit, Regulatory Affairs, and Medical Directors; supporting audits, regulatory reviews, accreditation surveys, delegation oversight, and corrective action plans; and ensuring appropriate audit trails, evidence-based criteria, and timely remediation. The Director leads program evaluation and performance improvement by assessing operational effectiveness, utilization trends, regulatory performance, quality outcomes, provider and member experience, and opportunities for improvement. The role uses analytics, dashboards, and reporting to identify trends and root causes, and collaborates with Finance, Affordability, Medical Economics, Population Health, Clinical Leadership, and other stakeholders to support appropriate utilization, reduce avoidable costs, optimize site-of-service opportunities, and strengthen value-based outcomes. Related initiatives may include avoidable utilization reduction, complex case review, discharge milestone management, workflow standardization, modernization, and technology-enabled improvements. The position leads a multi-level organization of managers, supervisors, nurse reviewers, and other clinical review staff. It sets expectations, coaches and develops employees, supports succession and competency development, and promotes engagement, accountability, change readiness, cross-functional collaboration, and operational excellence. The Director also oversees delegated vendors and contracted partners, monitors performance against contractual, clinical, quality, operational, and regulatory expectations, and works with internal and external stakeholders to address concerns and implement improvements. Performs other responsibilities and duties as assigned or directed.

Requirements

Bachelor’s degree in Nursing.
Seven years of progressive healthcare leadership experience, including at least five years of management experience in utilization management, care management, clinical operations, health plan operations, or managed care.
Demonstrated experience managing clinical review functions such as Prior Authorization, Prospective Review, Concurrent Review, facility review, or related utilization management operations.
Advanced knowledge of utilization management principles, clinical review methodologies, healthcare delivery systems, evidence-based clinical criteria, medical necessity review, and health plan operations.
Strong understanding of CMS, NCQA, Hawaii Medicaid, Medicare Advantage, Commercial, Federal, contractual, and accreditation requirements.
Effective verbal and written communication skills, including the ability to present complex clinical, operational, and regulatory information to leadership and cross-functional stakeholders.
Strong analytical, problem-solving, organizational, and decision-making skills, including the ability to interpret utilization trends, operational metrics, quality results, and regulatory performance indicators.
Demonstrated skill leading operational teams, managing complex priorities, influencing stakeholders, and driving measurable business outcomes in a highly regulated environment.
Utilization management/utilization review experience using nationally recognized clinical review criteria.
Intermediate to advanced working knowledge of Microsoft Office applications, including Word, Excel, Outlook, and PowerPoint.
Current unrestricted Registered Nurse (RN) license.
Hawaii RN license required or ability to obtain upon hire.

Responsibilities

Develop and execute strategic plans and provide operational leadership for Clinical Review and utilization review functions.
Establish consistent workflows, staffing models, performance expectations, and clinical review decision-making processes across teams.
Manage departmental budget planning, workforce forecasting, staffing strategy, resource allocation, and financial stewardship.
Ensure clinical resources are aligned to top-of-license work and operations are timely, accurate, member-centered, and scalable.
Oversee complex utilization review cases, high-cost claim reviews, high-needs member populations, and multidisciplinary review processes.
Account for turnaround time, quality, productivity, service, and departmental performance goals.
Maintain oversight of regulatory compliance, accreditation readiness, and quality for Clinical Review operations.
Partner with Compliance, Quality, Audit, Regulatory Affairs, and Medical Directors on requirements, decision standards, documentation, and notification timeframes.
Lead or support audit readiness, regulatory reviews, accreditation surveys, delegation oversight, quality assessments, and corrective action plans.
Ensure appropriate audit trails, consistent use of evidence-based clinical criteria, and timely remediation of identified gaps.
Evaluate Clinical Review and Utilization Management program performance, operational effectiveness, utilization trends, quality outcomes, and provider and member experience.
Use analytics, dashboards, and performance reporting to identify trends, root causes, variation, and improvement opportunities.
Collaborate with enterprise partners to support appropriate utilization, reduce avoidable healthcare costs, optimize site-of-service opportunities, and strengthen value-based outcomes.
Lead or support initiatives involving avoidable utilization reduction, complex case review, discharge milestone management, modernization, workflow standardization, and technology-enabled improvements.
Lead, coach, and develop managers, supervisors, nurse reviewers, and other clinical review staff.
Set expectations for performance, productivity, quality, documentation, regulatory knowledge, and member/provider service.
Support professional development, succession planning, competency development, and change readiness.
Promote cross-functional collaboration and innovative approaches to improving operations, team effectiveness, and business outcomes.
Oversee delegated vendors, contracted partners, and external clinical service providers to ensure they meet contractual, clinical, quality, operational, and regulatory expectations.
Monitor vendor performance through metrics, scorecards, service level expectations, audit results, and corrective action plans.
Partner with internal stakeholders to address vendor performance concerns and implement improvement strategies.
Perform other miscellaneous responsibilities and duties as assigned or directed.