Manager, Clinical Review

HMSA•Honolulu, HI

3d•Hybrid

About The Position

This role involves managing multiple units/teams and staff across various locations, fostering a collaborative and growth-oriented work environment. The Manager will provide leadership and direction to align with HMSA's strategic initiatives, mission, and industry best practices. Key responsibilities include ensuring compliance with HMSA, NCQA, and DOL standards for preauthorization activities, overseeing legal and contractual standards for precertification, payment determinations, and concurrent reviews, and managing multi-department QUEST Integration programs for LTSS, CIS, and EVV. The position also requires serving as a subject matter expert, collaborating on program development and implementation, hiring and developing staff, managing resources (budget, staff, support), coordinating workflows, resolving complex inquiries, and performing special projects.

Requirements

Bachelor's degree and five years of related work experience; or an equivalent combination of education and related work experience.
Two years of supervisory, management or leadership experience.
Current Nursing License in the state of Hawaii as a Registered Nurse and three (3) years clinical experience
Experience training staff.
Experience developing workflows and training materials.
Experience working in the healthcare industry
Knowledge of Healthcare Utilization Management programs
Some knowledge of CPT-4, HCPCS, ICD-10 and other claims coding systems, and UB-04 and HCFA 1500 forms.
Basic working knowledge of Microsoft Office applications. Including but not limited to Word, Excel, Outlook and Power Point.
Registered Nurse (RN) in the state of Hawaii.

Responsibilities

Manage multiple units/teams and staff in multiple locations, fostering a work environment that encourages teamwork, promotes personal growth and learning.
Provide leadership and direction to align with HMSA strategic initiatives and mission, as well as best practices in the industry.
Provide leadership, direction and support to the teams to ensure compliance with HMSA, NCQA and DOL standards governing the timeliness and quality of preauthorization activities.
Oversee compliance with legal and contractual standards related to precertification, payment determinations and concurrent reviews so that cases are reviewed timely and in accordance with HMSA's policies and benefits and accreditation standards.
Manage the multi-department QUEST Integration programs associated with Long-Term Services Support (LTSS), Community Integration Services (CIS) and Electronic Visit Verification (EVV).
Serve as a subject matter expert for MM, leading and/or participating in internal committees, workgroups and projects.
Oversee and collaborate with internal and external partners in the development and implementation of new or updated programs, workflows, policies & procedures system solutions to support the objectives of the respective team(s).
Hire, develop, coach and mentor staff to effectively meet corporate and department goals / objectives associated with management of the benefit cost trend through the implementation of utilization management activities.
Assess, identify and manage the appropriate resources needed to effectively meet HMSA Center business goals (budget, staff, support, coaching, etc.).
Allocate and re-allocate the appropriate resources based on workload and/or changing business needs.
Collaborate on a regular basis with departmental management teams to develop, implement and create coordination among all workflows and processes among multiple internal teams.
Research and resolve complex and/or high-level member and provider inquiries.
Perform special projects as assigned.