Registered Professional Nurse III, Utilization Review

Job Description

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 a detail-oriented Registered Professional Nurse III to support our Utilization Review and Appeals functions. This role is responsible for evaluating the medical necessity and appropriateness of patient care while assisting with appeals to secure reimbursement and ensure compliance with regulatory and payer requirements. The ideal candidate will combine strong clinical knowledge with analytical and communication skills to support both patient care quality and organizational financial performance.

• Perform utilization reviews for inpatient admissions and continued stays using nationally recognized criteria to determine medical necessity and appropriate level of care.
• Conduct concurrent and retrospective chart reviews to validate clinical documentation, treatment plans, and patient progress.
• Assist with appeals of denied claims by analyzing records, identifying discrepancies, and gathering supporting documentation to demonstrate medical necessity.
• Collaborate with case managers, physicians, Patient Financial Services, and external payers to ensure compliance with authorization and reimbursement requirements.
• Communicate effectively with interdisciplinary teams and external stakeholders to resolve issues related to level of care, coverage, and documentation.
• Serve as a resource for utilization review and appeals processes 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 six (6) months of professional nursing experience.
• 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.

• Knowledge of utilization review, reimbursement processes, and insurance guidelines.
• Strong clinical assessment, analytical thinking, and problem-solving abilities.
• Ability to interpret medical records, identify gaps, and support appeals with evidence-based rationale.
• Effective communication and collaboration skills across multidisciplinary teams.
• Strong organizational skills and ability to manage multiple priorities in a fast-paced environment.

Join a dedicated healthcare team committed to delivering high-quality care while supporting efficient and effective utilization of healthcare resources for our island community.

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 (Use the "Apply for this Job" box below). or .

• 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…