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Prior Authorization Utilization Review Jobs in Hawaii

AlohaCare

Medical Director

Honolulu, HI · On-site

$151.54 - $185.98/hr

The Medical Director participates in activities such as prior authorization, appeals and grievances ... Performs medical review activities pertaining to utilization review, quality assurance, and medical ...

AlohaCare

Medical Director

Honolulu, HI

The Medical Director participates in activities such as prior authorization, appeals and grievances ... Performs medical review activities pertaining to utilization review, quality assurance, and medical ...

AlohaCare

Medical Director

Honolulu, HI

The Medical Director participates in activities such as prior authorization, appeals and grievances ... Performs medical review activities pertaining to utilization review, quality assurance, and medical ...

AlohaCare

Medical Director

Honolulu, HI · On-site

$110 - $135/hr

The Medical Director participates in activities such as prior authorization, appeals and grievances ... Performs medical review activities pertaining to utilization review, quality assurance, and medical ...

AlohaCare

Medical Director

Honolulu, HI

The Medical Director participates in activities such as prior authorization, appeals and grievances ... Performs medical review activities pertaining to utilization review, quality assurance, and medical ...

Pharmacy Careers

Formulary Management Pharmacist

Honolulu, HI · On-site

$57.50 - $69.25/hr

Evaluate and review new drug products for formulary inclusion or exclusion. * Analyze clinical ... Provide clinical support for utilization management, prior-authorization criteria, and step-therapy ...

Pharmacy Careers

Formulary Management Pharmacist

Ewa Beach, HI · On-site

$60.25 - $72.50/hr

Evaluate and review new drug products for formulary inclusion or exclusion. * Analyze clinical ... Provide clinical support for utilization management, prior-authorization criteria, and step-therapy ...

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Prior Authorization Utilization Review information

What is a Prior Authorization Utilization Review specialist?

A Prior Authorization Utilization Review specialist is a healthcare professional responsible for evaluating medical service requests to ensure they meet specific criteria for approval before services are provided. Their main role is to review clinical information, verify medical necessity, and ensure compliance with insurance policies and guidelines. They act as a liaison between healthcare providers, insurance companies, and patients to facilitate timely and accurate authorization decisions. This process helps to manage healthcare costs and ensure patients receive appropriate care.

What are the key skills and qualifications needed to thrive as a Prior Authorization Utilization Review specialist?

To thrive as a Prior Authorization Utilization Review Specialist, you need a strong understanding of medical terminology, insurance guidelines, and clinical criteria, often supported by a degree in healthcare or nursing and relevant certification (such as RN or LPN). Familiarity with prior authorization software, electronic health record (EHR) systems, and payer portals is typically required. Attention to detail, strong communication skills, and the ability to multitask help professionals excel in this role. These competencies ensure accurate and timely processing of authorizations, reducing delays in patient care and ensuring compliance with payer requirements.

What are some common challenges faced by professionals in Prior Authorization Utilization Review roles, and how can these be managed?

Professionals in Prior Authorization Utilization Review often encounter challenges such as navigating complex insurance policies, managing high volumes of requests, and ensuring timely communication between providers and payers. Staying organized, developing a thorough understanding of payer guidelines, and maintaining clear, consistent communication are key strategies for managing these challenges. Many teams also rely on workflow management tools and regular team huddles to streamline processes and ensure all cases are handled efficiently.

What is the difference between Prior Authorization Utilization Review vs Medical Reviewer?

AspectPrior Authorization Utilization ReviewMedical Reviewer
CredentialsLicensed healthcare professionals, often with certifications in utilization reviewLicensed physicians or healthcare providers with clinical expertise
Work EnvironmentInsurance companies, healthcare organizations, or third-party review firmsHospitals, clinics, insurance companies, or consulting firms
Primary FocusAssessing the necessity of procedures or treatments before approvalEvaluating clinical records to determine medical necessity and appropriateness

While both roles involve clinical assessment, Prior Authorization Utilization Review focuses on pre-authorization decisions for treatments, whereas Medical Review involves detailed clinical evaluation of patient records to determine medical necessity. Both require healthcare credentials and are integral to healthcare quality and cost management.

What are popular job titles related to Prior Authorization Utilization Review jobs in Hawaii?

For Prior Authorization Utilization Review jobs in Hawaii, the most frequently searched job titles are:

What job categories do people searching Prior Authorization Utilization Review jobs in Hawaii look for?

The top searched job categories for Prior Authorization Utilization Review jobs in Hawaii are:

What cities in Hawaii are hiring for Prior Authorization Utilization Review jobs?

Cities in Hawaii with the most Prior Authorization Utilization Review job openings:

Prior Authorization Utilization Review jobs near you

Concurrent Nurse Reviewer - Facility Utilization Review Unit

Honolulu, HI • On-site

HMSA
Insurance Services • 1 - 5K employees
Learn more about HMSAexternal

Other

This job post has expired 1 day ago. Applications are no longer accepted.

Job description

  1. Applies appropriate medical necessity criteria from established medical policies and clinical practice guidelines to apply concurrent review determinations as described in the Medical Management UM work plan.
    • This detailed clinical judgment includes determination of inpatient hospital stays as medically appropriate for the member's clinical condition or whether the stay requires referral to a Medical Director for potential denial.
    • 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 relationship management, coordination of services, resource management, education, patient advocacy, and related interventions to:
      • Promote improved quality of care and/or life
      • Promote cost effective medical outcomes
      • Prevent hospitalization when possible and appropriate
      • Promote decreased lengths of hospital stays when appropriate
      • Ensure the quality-of-care member is receiving during hospital stay is appropriate
      • Ensure appropriate levels of care are received by patients
      • Consult with Medical Directors on potential quality issues encountered during review of medical records in situations when the complexity of the member's medical, surgical and/or pharmaceutical management is unclear and may require further review or intervention and follow up with attending physicians, hospitalists, or other facility staff
  2. Provide appropriate consultation and referral to Case Management or QUEST Integration program as appropriate
  3. Identify appropriate alternative and non-traditional resources and demonstrate creativity in managing each case to fully utilize all available inpatient and community resources.
  4. Identifies cost savings and accurately records all communications and interventions.
  5. Evaluates 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.
  6. Communicates timely, accurate information either verbally or in writing using clinical judgment, knowledge of medical/reimbursement policies and plan benefits to internal MM staff, other internal departments (Claims Administration, Customer Relations, etc.), providers, members, and other authorized persons.
    • For denied services, ensures the denial, benefit and appeal language are accurate and consistent with department procedures, accreditation, and regulatory guidelines.
  7. Identifies and refers members with specific medical and/or behavioral health needs or complex case management and collaborates with case management staff as needed. Also identifies and refers quality of care issues and suspected fraud, waste, or abuse to the appropriate departments.
  8. Performs all other miscellaneous responsibilities and duties as assigned or directed.
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