Director, Clinical Review

HMSA•Honolulu, HI

22h•Hybrid

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 consistent workflows, staffing models, performance expectations, and clinical review decision-making processes aligned with enterprise objectives, regulatory requirements, and affordability initiatives. It is responsible for departmental budget planning, workforce forecasting, staffing strategy, resource allocation, and financial stewardship, and ensures clinical resources are directed toward top-of-license work and timely, accurate, member-centered, scalable operations. The Director oversees complex utilization review cases, high-cost claim reviews, high-needs member populations, and multidisciplinary review processes, and is accountable for turnaround time, quality, productivity, service, and departmental performance goals. The Director leads regulatory compliance, accreditation readiness, and quality oversight for Clinical Review. This includes maintaining knowledge of applicable federal, state, contractual, accreditation, and HMSA requirements; partnering with Compliance, Quality, Audit, Regulatory Affairs, and Medical Directors; and leading or supporting audit readiness, regulatory reviews, accreditation surveys, delegation oversight, quality assessments, and corrective action plans. The role ensures appropriate audit trails, consistent use of evidence-based clinical criteria, and timely remediation of identified gaps. The role evaluates Clinical Review and Utilization Management program performance, using analytics, dashboards, and reporting to identify trends, root causes, variation, and improvement opportunities. In partnership with Finance, Affordability, Medical Economics, Population Health, Clinical Leadership, and other stakeholders, the Director supports appropriate utilization, reduced avoidable healthcare costs, optimized site-of-service opportunities, and value-based outcomes. Initiatives may include avoidable utilization reduction, complex case review, discharge milestone management, review modernization, workflow standardization, and technology-enabled improvements. The Director leads managers, supervisors, nurse reviewers, and other clinical review staff, providing coaching and development and establishing expectations for performance, productivity, quality, documentation, regulatory knowledge, and member and provider service. The role supports professional development, succession planning, competency development, and change readiness, while promoting collaboration and innovation. It also manages oversight of delegated vendors, contracted partners, and external clinical service providers, monitoring performance against contractual, clinical, quality, operational, and regulatory expectations and working with internal and external partners to address concerns and implement improvements. Other responsibilities may be 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 ability to lead operational teams, manage complex priorities, influence stakeholders, and drive measurable business outcomes in a highly regulated environment.
Utilization management or 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.
Plan departmental budgets, forecast workforce needs, set staffing strategies, allocate resources, and steward financial resources.
Align clinical resources with top-of-license work and support timely, accurate, member-centered, and scalable operations.
Oversee complex utilization review cases, high-cost claim reviews, high-needs member populations, and multidisciplinary review processes.
Meet turnaround time, quality, productivity, service, and departmental performance goals.
Maintain knowledge of federal, state, contractual, accreditation, and organizational requirements governing utilization management.
Partner with Compliance, Quality, Audit, Regulatory Affairs, Medical Directors, and other stakeholders to ensure compliance with decision standards, documentation expectations, and notification timeframes.
Lead or support audit readiness, regulatory reviews, accreditation surveys, delegation oversight, internal quality assessments, and corrective action plans.
Ensure appropriate audit trails, consistent application of evidence-based clinical criteria, and timely remediation of identified gaps.
Evaluate Clinical Review and Utilization Management program performance, including operational effectiveness, utilization trends, regulatory performance, quality outcomes, and provider and member experience.
Use data analytics, dashboards, and performance reporting to identify trends, root causes, variation, and improvement opportunities.
Partner with enterprise stakeholders 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, clinical review 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 and 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; monitor performance through metrics, scorecards, service levels, audits, and corrective action plans.
Collaborate with internal and external partners to address vendor performance concerns and implement improvement strategies.
Perform other miscellaneous responsibilities and duties as assigned or directed.