Manager, Clinical Review

Employment Type

Full-time

Exempt or Non-Exempt

Exempt

Job Summary

• Hybrid Work Environment - Must reside in Hawaii**
  
  
  

Pay Range: $68,000 to $133,000

Note: Individuals typically begin between the minimum to middle of the pay range

Oversight of the nurse review teams that conducts medical necessity review as part of HMSA Utilization Management program that includes prior authorization, payment determination, post-service claim reviews, QI specific programs, out-of-network and exception reviews to support HMSA's strategic goals and compliance with HMSA policies and procedures, government regulations, laws and accreditation standards.

Minimum Qualifications

• 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.
  
  
  

Duties And Responsibilities

• Management of 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.
• Management of 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. Such groups may be focused on problem resolution, program updates or implementation of new programs and initiatives that support compliance and/or HMSA goals.
• Oversees 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).
• Hires, develops, 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.