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HMSA

Nurse Reviewer - Clinical Review Unit

Kapolei, HI · On-site

The Nurse Reviewer must follow each line of business requirements and each accrediting body's (CMS, NCQA, HSAG) requirements for each inpatient admission. Responsibilities include using effective ...

Care Navigators On Demand

$39 - $45/hr

Knowledge of NCQA, CMS, HSAG, and health plan requirements related to utilization management. 6.Knowledgeable with the pre-authorization process and workflow, with prior authorization experience ...

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How much do hsag jobs pay per hour?

As of Aug 26, 2026, the average hourly pay for hsag in the United States is $17.98, according to ZipRecruiter salary data. Most workers in this role earn between $14.66 and $20.19 per hour, depending on experience, location, and employer.

What is a HSAG?

HSAG stands for Health Services Advisory Group. HSAGs are organizations that work to improve the quality of healthcare services by evaluating care, providing technical assistance, and supporting quality improvement initiatives for healthcare providers and government agencies. They often serve as Quality Improvement Organizations (QIOs) for Medicare and Medicaid programs, helping to ensure that beneficiaries receive safe, effective, and efficient care. HSAGs may also conduct audits, offer training, and support data analysis to enhance healthcare outcomes.

What are the key skills and qualifications needed to thrive as a Health Services Advisory Group (HSAG) professional?

To thrive as a Health Services Advisory Group (HSAG) professional, you typically need expertise in healthcare quality improvement, data analysis, and regulatory compliance, often supported by a degree in nursing, public health, or a related field. Familiarity with quality measurement tools, healthcare data systems, and CMS (Centers for Medicare & Medicaid Services) reporting platforms is essential. Strong analytical thinking, attention to detail, and effective communication are valuable soft skills in this role. These skills enable professionals to drive healthcare quality initiatives, ensure regulatory adherence, and collaborate effectively with healthcare organizations for optimal patient outcomes.

What are some common challenges faced by Health Services Advisory Group (HSAG) professionals when working on quality improvement projects?

Professionals at HSAG often encounter challenges such as managing diverse stakeholder expectations, navigating complex healthcare regulations, and addressing data quality issues when evaluating program outcomes. Collaborating with healthcare providers and government agencies requires strong communication and project management skills to ensure alignment and timely project delivery. Additionally, adapting to evolving healthcare standards while maintaining high-quality reporting can be demanding but offers significant opportunities for professional growth.

What is the difference between Hsag vs Safety Coordinator?

AspectHsagSafety Coordinator
CertificationsOSHA 30-hour, Hsag-specific trainingOSHA 30-hour, safety certifications
Work EnvironmentConstruction sites, industrial settingsOffice, construction sites, industrial environments
Employer & Industry UsageConstruction companies, industrial firmsConstruction, manufacturing, corporate safety departments

Both Hsag and Safety Coordinator roles focus on safety compliance and risk management. Hsag typically refers to a specific safety role within construction or industrial settings, often requiring specialized training. Safety Coordinators have broader responsibilities across various industries, overseeing safety programs and compliance. While overlapping in certifications and work environments, Hsag roles are more specialized, whereas Safety Coordinators often handle wider safety management tasks.

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Cities with the most Hsag job openings:

What states have the most Hsag jobs?

States with the most job openings for Hsag jobs include:

What job categories do people searching Hsag jobs look for?

The top searched job categories for Hsag jobs are:

Hsag jobs near you
Infographic showing various Hsag job openings in the United States as of August 2026, with employment types broken down into 100% Full Time. Highlights an 100% In-person job distribution, with an average salary of $37,391 per year, or $18 per hour.

Nurse Reviewer - Clinical Review Unit

Kapolei, HI • On-site

Hawaii Medical Service Association
Insurance Services • 1 - 5K employees
Learn more about Hawaii Medical Service Associationexternal

Full-time

Posted 6 days ago

Job description

  1. Utilize medical necessity criteria from established medical policies and clinical practice guidelines to render precertification determinations as described in the Medical Management UM work plan. This detailed clinical judgment includes evaluating whether the requested service is a covered benefit under the member's health plan, is medically appropriate for the member's clinical condition or whether the request requires referral to a Medical Director for potential denial of the request. The Nurse Reviewer must follow each line of business' requirements and each accrediting body's (CMS, NCQA, HSAG) requirements for each request. Assists on inquiries from external parties such as the State Insurance Commissioner and from the Legal Department. Responsibilities include, but are not limited to:
  2. Demonstrate understanding and application of over 250 Guide to Benefits, Evidence of Coverage, Plan Brochure, and Member Handbook. HMSA annually updated medical and drug policies, medical protocols, National Comprehensive Cancer Network, Milliman Care Guidelines, Drugdex, etc. to determine the medical necessity of urgent and non-urgent precertification requests. Urgent requests must be completed within 72 hours and non-urgent requests within 15 calendar days.
  3. Use clinical judgment, medical necessity guidelines and plan benefits to determine approval, potential denial or alternative treatment of each urgent or non-urgent precertification request. Settings include inpatient, outpatient, in-state, out-of state and out-of country.
  4. Document clinical case summary and review outcome of each review appropriately to meet regulatory and program requirements.
  5. Review various types of services, including but not limited to:
    • Transplants
    • Air Ambulance
    • Chemotherapy
    • Clinical trials
    • Genetic testing
    • Cancer treatments/radiation therapy
    • Experimental/Investigational Services/Devices
    • New Technology
  6. Utilize medical necessity criteria from established medical policies and clinical practice guidelines to render precertification determinations as described in the Medical Management UM work plan. This detailed clinical judgment includes evaluating whether the requested service is a covered benefit under the member's health plan, is medically appropriate for the member's clinical condition or whether the request requires referral to a Medical Director for potential denial of the request. The Nurse Reviewer must follow each line of business' requirements and each accrediting body's (CMS, NCQA, HSAG) requirements for each request. Assists on inquiries from external parties such as the State Insurance Commissioner and from the Legal Department. Responsibilities include, but are not limited to:
    • Call providers when additional clinical information is required to clarify or complete a complex precertification determination.
    • Approve precertification requests based on clinical judgment using criteria, medical record documentation and other information received from the provider.
    • Consult with Medical Directors on requests which do not meet clinical criteria and offer alternative covered health care options as appropriate.
    • Consult Medical Directors on potential quality issues identified during review of medical records. Refer cases to Integrated Health Management, Pharmacy Department or Benefits Integrity Department depending on the concern.
  7. Evaluate suspended claims against medical records to determine the medical necessity and appropriateness of medical services, identify irregularities such as over or under-utilization of services, potential up-coding, over billing, etc.
  8. Communicate timely, accurate information either verbally, electronically or in writing using clinical judgment, knowledge of medical/reimbursement policies and plan benefits to providers, members as well as internal MM staff and other internal departments (Claims Administration, Customer Relations, Provider Contracting, etc.). For denied services, ensure the denial, benefit and appeal language are accurate and consistent with department procedures, accreditation and regulatory guidelines.
  9. Identify and refer members with specific medical and/or behavioral health needs or complex case management and collaborate with medical and behavioral case management staff. Identify and refer quality of care issues and suspected fraud, waste or abuse to the appropriate departments.
  10. Perform pre-screening assessment of incoming pre-certification requests to ensure appropriateness of review. Advises non-clinical staff on clinical and coding questions to ensure correct system processes and entries.

  1. Associates Degree in Nursing
  2. Current, unrestricted Nursing License in the state of Hawaii as an RN or LPN
  3. Two years clinical, case management or utilization management related experience
  4. Knowledge of current standards of care to be followed for a given diagnosis and the normative values of medical tests and procedures.
  5. Strong organizational skills
  6. Good communication skills both verbally and written
  7. Multi-tasking skills
  8. Critical thinking skills
  9. Analytical skills
  10. Basic knowledge of Microsoft Office applications. Including but not limited to Word, Excel, and Outlook.
  11. Currently licensed in Hawaii as an RN or LPN
    (if applicable upon hire, proof of licensure to be provided by employee or confirmed by Human Resources)

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