Director, Clinical Review
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- United States
- Work type
- Hybrid
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- Provide strategic and operational leadership for Clinical Review operations
- Develops and executes strategic plans and provides operational leadership for Clinical Review functions, including Prior Authorization, Prospective Review, Concurrent Review, facility review, inpatient, observation, skilled nursing facility, out-of-state, and other utilization review activities, ensuring alignment with HMSA's enterprise objectives, regulatory requirements, and affordability initiatives. Establish consistent workflows, staffing models, performance expectations, and clinical review decision-making processes across teams.
- Responsible for departmental budget planning, workforce forecasting, staffing strategy, resource allocation, and financial stewardship in support of organizational and operational goals. Ensures clinical resources are aligned to top-of-license work and support operational execution that is timely, accurate, member-centered, and scalable. Oversee complex utilization review cases, high-cost claim reviews, high-needs member populations, and multidisciplinary review processes requiring collaboration with Medical Directors and enterprise partners. Accountable for achievement of turnaround time, quality, productivity, service, and departmental performance goals.
- Lead regulatory compliance, accreditation readiness, and quality oversight for Clinical Review
- Maintain current knowledge of federal, state, contractual, accreditation, and HMSA requirements governing utilization management activities, including CMS, NCQA, Hawaii Medicaid, Medicare Advantage, Commercial, Federal, and other applicable program requirements. Partner with Compliance, Quality, Audit, Regulatory Affairs, and Medical Directors to ensure ongoing adherence to clinical review requirements, medical necessity decision standards, documentation expectations, and notification timeframes. Lead or support audit readiness activities, regulatory reviews, accreditation surveys, delegation oversight activities, internal quality assessments, and corrective action plans. Ensure clinical review operations maintain appropriate audit trails, consistent application of evidence-based clinical criteria, and timely remediation of identified gaps.
- Drive program evaluation, performance improvement, and affordability outcomes
- Provide leadership for the ongoing and annual evaluation of Clinical Review and Utilization Management program performance, including operational effectiveness, utilization trends, regulatory performance, quality outcomes, provider and member experience, and opportunities for improvement. Use data analytics, dashboards, and performance reporting to identify trends, root causes, variation, and improvement opportunities. Partner with Finance, Affordability, Medical Economics, Population Health, Clinical Leadership, and enterprise stakeholders to support appropriate utilization, reduce avoidable healthcare costs, optimize site-of-service opportunities, and strengthen value-based outcomes. Lead or support initiatives related to avoidable utilization reduction, complex case review, discharge milestone management, clinical review modernization, workflow standardization, and technology-enabled improvements.
- Provide leadership, coaching, and workforce development
- Leads a multi-level clinical review organization consisting of managers, supervisors, nurse reviewers, and other clinical review staff, providing leadership, coaching, and development to drive workforce performance, engagement, accountability, and operational excellence in support of HMSA's strategic and operational objectives. Establish clear expectations for performance, productivity, quality, documentation, regulatory knowledge, and member/provider service. Support professional development, succession planning, competency development, and change readiness. Promote cross-functional collaboration and encourage innovative approaches to improving clinical review operations, team effectiveness, and business outcomes.
- Manage vendor oversight and cross-functional collaboration
- Collaborate with delegated vendors, contracted partners, external clinical service providers, and internal stakeholders to ensure vendor-supported clinical review and utilization management activities meet contractual, clinical, quality, operational, and regulatory expectations. Monitor vendor performance through reporting metrics, scorecards, service level expectations, audit results, and corrective action plans. Partner with Compliance, Quality, Vendor Management, Provider Contracting, Medical Directors, and operational leaders to address performance concerns and implement improvement strategies.
- Performs all other miscellaneous responsibilities and duties as assigned or directed.
- Bachelor's degree in Nursing.
- Seven years of progressive healthcare leadership experience, including at least five years of management experience in utilization management, care management, clinical operations, health plan operations, or managed care.
- Demonstrated experience managing clinical review functions such as Prior Authorization, Prospective Review, Concurrent Review, facility review, or related utilization management operations.
- Advanced knowledge of utilization management principles, clinical review methodologies, healthcare delivery systems, evidence-based clinical criteria, medical necessity review, and health plan operations.
- Strong understanding of CMS, NCQA, Hawaii Medicaid, Medicare Advantage, Commercial, Federal, contractual, and accreditation requirements.
- Effective verbal and written communication skills, including the ability to present complex clinical, operational, and regulatory information to leadership and cross-functional stakeholders.
- Strong analytical, problem-solving, organizational, and decision-making skills with the ability to interpret utilization trends, operational metrics, quality results, and regulatory performance indicators.
- Demonstrated skill leading operational teams, managing complex priorities, influencing stakeholders, and driving measurable business outcomes in a highly regulated environment.
- Utilization management/utilization review experience using nationally recognized clinical review criteria.
Intermediate to advanced working knowledge of Microsoft Office applications, including Word, Excel, Outlook, and PowerPoint. - Current unrestricted Registered Nurse (RN) license. Hawaii RN license required or ability to obtain upon hire.
