Manager Optum Utilization Review Jobs in Hawaii (NOW HIRING)

Join Hilo Benioff Medical Center and be part of a team that proudly cares for our friends, family, and neighbors across East Hawaiʻi.

Hilo Benioff Medical Center, part of the East Hawaii Region of Hawaii Health Systems Corporation, is seeking an experienced Registered Professional Nurse IV to join our Utilization Review team. This role is responsible for ensuring the medical necessity, appropriateness, and efficiency of patient care while supporting reimbursement through comprehensive clinical reviews. The ideal candidate will bring strong clinical expertise, analytical skills, and a collaborative approach to optimizing patient outcomes and organizational performance.

• Conduct utilization reviews for inpatient admissions and continued stays using InterQual or other nationally recognized criteria to determine medical necessity and appropriate level of care.
• Collaborate with physicians, case managers, and interdisciplinary teams to ensure accurate documentation, appropriate treatment plans, and compliance with regulatory and payer requirements.
• Communicate with insurance carriers and Patient Financial Services to obtain authorizations, provide clinical updates, and resolve reimbursement-related issues.
• Perform concurrent medical record reviews to validate diagnoses, treatments, and alignment with documented care plans.
• Serve as a clinical resource and liaison across departments, including Admitting, Medical Records, and Patient Services, to support pre-authorization and utilization review processes.
• Support cost containment efforts and quality improvement initiatives while maintaining compliance with hospital policies, accreditation standards, and confidentiality requirements.

• Education: Graduate of an accredited school of nursing (Bachelor’s Degree in Nursing preferred).
• Experience: Minimum of one and one-half (1.5) years of professional nursing experience; demonstrated leadership.
• Certification: Basic Life Support (BLS) certification required within one (1) month of hire; Utilization Review certification preferred.
• Licensure: Current, valid Registered Nurse (RN) license in the State of Hawaiʻi.

• Strong knowledge of utilization review processes, reimbursement systems, and insurance guidelines.
• Ability to analyze clinical documentation, assess medical necessity, and support accurate level-of-care determinations.
• Excellent communication, problem-solving, and collaboration skills across multidisciplinary teams.
• High level of independence, organization, and attention to detail in a fast-paced healthcare environment.

As the Big Island’s leading providers of inpatient and outpatient care, the East Hawaii Region of Hawai`i Health Systems Corporation (HHSC), consisting of Hilo Benioff Medical Center, Honoka'a Hospital, Ka′u Hospital, Yukio Okutsu State Veterans Home, East Hawaii Medical Group and East Hawaii Health Pharmacy, delivers a full range of services and programs. Our three hospitals include 290 beds and more than 1,900 employees. Our medical staff is comprised of 250 physicians, physician assistants and Advanced Practice Registered Nurses, representing 33 specialties. East Hawaii Health is our network of clinics offering primary and specialty care. Hilo Benioff Medical Center functions as a Level III Trauma Center, which includes the second busiest emergency room in the state, providing 24-hour care and serving more than 50,000 patients annually. Honoka'a Hospital and Ka′u Hospital are designated as Critical Access Hospitals. To learn more about the East Hawaii Region, please watch our Video Yearbook or visit www.hbmc.org, www.honokaahospital.org or www.kauhospital.org.

• 13 paid holidays each year (104 hours); 14 (112 hours) during election years*
• 21 paid vacation days (168 hours) per year*
• 21 paid sick days (168 hours) per year*
• Medical, dental, vision, and prescription plans
• Employee Assistance Program
• Participation in the State of Hawaii’s retirement system
• Potential eligibility for various student loan repayment & scholarship programs

* Rates listed for paid holidays, vacation and sick days are for 1.0 Full Time Equivalent (FTE) positions assigned to 8 hour shifts. Accruals for these benefits are otherwise prorated based on FTE.

Offers of employment will be contingent on successfully passing a pre-employment examination, which includes a drug screen and other regulatory medical requirements such as, but not limited to, a tuberculosis (TB) screen. The cost for drug screening and blood draw for QuantiFERON and Titers, shall be borne by the Hawaii Health Systems Corporation.

As part of the recruiting process for this position, external applicants (job applicants NOTemployed byHHSC’s East Hawaii Region)are required to complete pre-employment assessments shortly after application submission. If you are notan employee of the East Hawaii Region of HHSC, youwill receive an email containing assessment instructions. We ask that you complete the assessments within two days of receipt of the request.

The East Hawaii Region of Hawaii Health Systems Corporation is a drug free workplace and an Equal Opportunity Employer.

Must be available to work shifts, weekends and holidays as necessary based on hospital operations. Services are provided 24/7.