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CategoryHealthcare
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No of Jobs1
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Apply Before12/08/2025
Description
Nurse Reviewer - Clinical Review Unit
HMSA - Kapolei, HI
Job Title: Nurse Reviewer - Clinical Review Unit
Position: Precertification Nurse Reviewer
Job Type: Full Time
Pay:
Shift:
Work Type:
Location
Address:
City: Kapolei
State: HI
ZIP Code:
Job Responsibilities
- Utilize medical necessity criteria from established medical policies and clinical practice guidelines to render precertification determinations.
- Evaluate whether the requested service is a covered benefit under the member's health plan and medically appropriate for the member's clinical condition.
- Refer requests to a Medical Director for potential denial when necessary.
- Follow line of business' and accrediting body's (CMS, NCQA, HSAG) requirements for each request.
- Assist inquiries from external parties such as the State Insurance Commissioner and Legal Department.
- Demonstrate understanding and application of various medical and drug policies, medical protocols and clinical guidelines.
- Complete urgent precertification requests within 72 hours and non-urgent requests within 15 calendar days.
- Document clinical case summary and review outcomes appropriately.
- Review various types of services such as transplants, air ambulance, chemotherapy, clinical trials, and genetic testing.
- Call providers when additional clinical information is required to clarify or complete precertification determinations.
- Approve precertification requests based on clinical judgment using criteria and medical record documentation.
- Consult with Medical Directors on requests that do not meet clinical criteria and offer alternative covered health care options.
- Evaluate suspended claims against medical records for medical necessity and appropriateness of services.
- Communicate timely and accurately with providers, members, and internal teams.
- Ensure denial and appeal language is accurate and consistent with procedures and regulatory guidelines.
- Identify and refer members with medical and/or behavioral health needs for case management.
- Perform pre-screening assessment of incoming precertification requests.
- Advise non-clinical staff on clinical and coding questions.
- Perform miscellaneous responsibilities as assigned or directed.
Required Skills
Core Skills
- Clinical judgment
- Understanding of medical necessity criteria
- Knowledge of medical/reimbursement policies
- Documentation skills
- Communication skills
Preferred Skills
- Experience with precertification processes
- Familiarity with healthcare regulations and accreditation bodies
- Ability to work with various healthcare professionals
Requirements
Experience:
Education:
License & Certification:
- Not specified
Schedule:
COVID-19 Requirements: Not Specified
Benefits
- Not specified
Supplemental Pay
- Not specified
Special Notes
- Not specified
Facility Details
Name: HMSA
Description: Not Specified
Specialties:
- Not specified
Mission: Not Specified
Job Info
Discipline:
Department:
Status:
Sourcing
Duration:
Experience:
Career Level:
No of Jobs:
1
Apply Before:
12/08/2025
Posted:
09/08/2025
