ZipRecruiter

Log In

1

Utilization Reviewer Jobs in Hawaii (NOW HIRING)

AlohaCare

Medical Director

Honolulu, HI · On-site

Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services, ensuring timely and quality ...

AlohaCare

Medical Director

Honolulu, HI · On-site

Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services, ensuring timely and quality ...

AlohaCare

Medical Director

Honolulu, HI · On-site

$110 - $135/hr

Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services, ensuring timely and quality ...

AlohaCare

Medical Director

Honolulu, HI

Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services, ensuring timely and quality ...

previous pagenext page

Showing results 21-40

All JobsUtilization Reviewer JobsUtilization Reviewer Jobs in Hawaii

Utilization Reviewer information

See Hawaii salary details

$32.2K

$39.5K

$45.7K

How much do utilization reviewer jobs pay per year?

As of Sep 2, 2026, the average yearly pay for utilization reviewer in Hawaii is $39,472.00, according to ZipRecruiter salary data. Most workers in this role earn between $35,300.00 and $43,600.00 per year, depending on experience, location, and employer.

What does a utilization reviewer do?

A Utilization Reviewer is a healthcare professional responsible for evaluating the necessity, appropriateness, and efficiency of medical services provided to patients. They review patient records, treatment plans, and insurance policies to ensure that care meets established guidelines and standards. Their role helps control healthcare costs while maintaining quality patient care and ensuring compliance with regulatory requirements. Utilization Reviewers often communicate with healthcare providers, insurance companies, and patients to gather information and make informed decisions.

What does a utilization reviewer do?

There are different types of Utilization Reviewer jobs, including Nurse Utilization Reviewers, Insurance Utilization Reviewers, Speech Therapy, Physical Therapy, and Occupational Therapy Utilization Reviewers. Regardless of the area of focus, a Utilization Reviewer is responsible for setting best practices, reviewing healthcare program requirements, ensuring the quality of care, controlling costs, and developing and implementing initiatives for review processes. Utilization Reviewers ensure compliance of programs, regularly audit patient and client records, work with staff to implement best practices and correct problem areas, monitor industry trends, and remain up-to-date and train others on industry standards and requirements.

What are the key skills and qualifications needed to thrive as a utilization reviewer?

To thrive as a Utilization Reviewer, you need a clinical background (such as RN or LCSW), in-depth knowledge of medical terminology, and an understanding of healthcare regulations and insurance guidelines. Familiarity with utilization management software, electronic health records (EHRs), and relevant certifications like CCM or URAC accreditation is typically required. Strong critical thinking, attention to detail, and effective communication skills help in evaluating patient care and collaborating with providers. These competencies are crucial for ensuring appropriate, cost-effective care while maintaining compliance with healthcare standards.

How does a utilization reviewer typically collaborate with healthcare providers to ensure appropriate patient care?

Utilization Reviewers work closely with physicians, nurses, and other healthcare professionals to assess the necessity and efficiency of medical services provided to patients. They review clinical documentation, verify that treatments meet established guidelines, and may discuss care plans directly with providers to clarify information or suggest alternatives. This collaboration ensures that patients receive appropriate care while controlling costs and complying with insurance or regulatory requirements. Effective communication and a thorough understanding of medical protocols are essential for success in this role.

What is the difference between Utilization Reviewer vs Medical Coder?

AspectUtilization ReviewerMedical Coder
Required CredentialsTypically requires healthcare-related certifications, such as RHIT, RHIA, or CPCUsually requires coding certifications like CPC, CCS, or CCS-P
Work EnvironmentHealthcare facilities, insurance companies, or utilization review organizationsHospitals, clinics, or medical billing companies
Employer & Industry UsageUsed in insurance, managed care, and healthcare administrationUsed in medical billing, coding, and health information management

While both roles work within healthcare settings, Utilization Reviewers focus on evaluating the necessity of medical services for insurance and care management, whereas Medical Coders translate medical records into standardized codes for billing and documentation. Understanding these differences helps professionals choose the right career path or job search focus.

How do I become a utilization review nurse?

To become a utilization review nurse, you typically need to hold a registered nurse (RN) license and have experience in clinical nursing. Additional certifications such as the Certified Professional Utilization Review (CPUR) or Certified Case Manager (CCM) can enhance job prospects, and strong knowledge of healthcare policies and documentation is essential.

Is utilization review a good job?

Utilization reviewers evaluate medical necessity and appropriateness of healthcare services, often working in healthcare or insurance settings. The role requires attention to detail, knowledge of healthcare policies, and sometimes certification, with typical schedules being standard business hours. It can offer stable employment and opportunities for advancement in healthcare administration.
More about Utilization Reviewer jobs

What are popular job titles related to Utilization Reviewer jobs in Hawaii?

For Utilization Reviewer jobs in Hawaii, the most frequently searched job titles are:

What job categories do people searching Utilization Reviewer jobs in Hawaii look for?

The top searched job categories for Utilization Reviewer jobs in Hawaii are:

What cities in Hawaii are hiring for Utilization Reviewer jobs?

Cities in Hawaii with the most Utilization Reviewer job openings:

What are popular job titles related to Utilization Reviewer jobs in HI?

For Utilization Reviewer jobs in HI, the most frequently searched job titles are:

Utilization Reviewer jobs near you
Infographic showing various Utilization Reviewer job openings in Hawaii as of August 2026, with employment types broken down into 67% Full Time, and 33% Part Time. Highlights an 74% In-person, and 26% Remote job distribution, with an average salary of $39,472 per year, or $19 per hour.

Nurse Reviewer - Clinical Review Unit

Hawaii Medical Service Association

Kapolei, HI • On-site

Full-time

Posted 13 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)

Apply