Nurse Reviewer - Clinical Review Unit

Hawaii Medical Service Association • Kapolei, HI

431d • $59,000 - $116,000 • Hybrid

About The Position

The Nurse Reviewer position at Hawaii Medical Service Association involves conducting detailed analysis and review of precertification requests, post-service, and suspended claims. The role requires applying clinical expertise to determine the appropriateness of care based on HMSA medical policies, plan benefits, and nationally accepted clinical guidelines. This position is essential for ensuring that healthcare services provided to members are medically necessary and covered under their health plans.

Requirements

• Associate's degree in Nursing.
• Current, unrestricted Nursing License in Hawaii as an RN or LPN.
• Two years of clinical, case management, or utilization management experience.
• Knowledge of current standards of care and normative values of medical tests.
• Strong organizational skills and good communication skills, both verbal and written.
• Analytical skills and basic knowledge of Microsoft Office applications.

Nice To Haves

• Experience with medical necessity criteria and clinical practice guidelines.
• Familiarity with HMSA medical and drug policies.

Responsibilities

• Conduct detailed analysis and review of precertification requests and claims.
• Utilize medical necessity criteria to render precertification determinations.
• Evaluate whether requested services are covered benefits and medically appropriate.
• Assist with inquiries from external parties such as the State Insurance Commissioner.
• Document clinical case summaries and review outcomes appropriately.
• Call providers for additional clinical information when necessary.
• Approve precertification requests based on clinical judgment and documentation.
• Consult with Medical Directors on requests that do not meet clinical criteria.
• Evaluate suspended claims against medical records for medical necessity.
• Communicate timely and accurate information to providers and members.

Benefits

• Hybrid work environment
• Competitive salary range of $59,000 - $116,000 per year

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Insurance Carriers and Related Activities
• Education Level: Associate degree