Prior Authorizations Nurse (RN) (Temporary)

Central California Alliance for Health; United States; Hybride; USD 102 000 - 118 000; Plein temps

Avantages offerts par ce poste

Medical benefits

Paid time off

Retirement plan

Résumé du poste

Central California Alliance for Health is hiring for a temporary full-time nursing role focusing on prior authorization and utilization management. The candidate will review requests using evidence-based standards and participate in UM Care Programs to ensure compliant utilization.

Requires current RN license in California, relevant nursing education, and experience with Medi-Cal/M CMS guidelines. Hybrid work arrangement with potential in-office and remote duties is offered.

Qualifications

• Current unrestricted RN license issued by California.
• Bachelor’s in Nursing or Associate’s with 5+ years in patient care; bachelor's may substitute for 2 years.
• Knowledge of managed care, Medicare D-SNP and Medi-Cal programs and related regulations.
• Experience with CMS guidelines and Local/National Coverage Determinations.
• Proficiency in Excel, PowerPoint, and database software.
• Ability to evaluate medical records, apply policies, and maintain records.

Responsabilités

• Ensures prior authorization requests meet contractual requirements and are reviewed using evidence-based standards.
• Participates in Utilization Management (UM) Care Programs.

Connaissances

Prior Authorization

Clinical nursing

MCG guidelines

Medi-Cal regs

CMS guidelines

Record interpretation

Formation

Bachelor’s in Nursing

Associate’s degree in Nursing

Outils

Excel

PowerPoint

Database software

Description du poste

OUR COMMITMENT TO A HUMAN HIRING PROCESS

We believe every candidate deserves thoughtful consideration. That’s why we do not use AI or automated systems to review applications. Every application is reviewed by a real human member of our team. Because we take the time to give each submission the attention it deserves, our review process may take a little longer — and we genuinely appreciate your patience as we work through applications carefully and respectfully.

SERVICE AREA PREFERENCE

While we encourage all interested applicants to apply, we do give priority to those who live in, or near, our service counties: Santa Cruz, Monterey, Merced, San Benito, and Mariposa. Our mission of accessible, quality health care guided by local innovation leads everything we do, and having team members who are connected to the communities we serve strengthens our ability to deliver on that commitment.

ABOUT THIS TEMP POSITION

This is a temporary position. The length of the assignment is estimated to go from August to the end of December 2026, but this is always dependent on business need, and these dates may change. While the assignment would be at the Alliance, you would be an employee of a temporary employment agency that we would connect you with if hired for this position. This is a full-time (40 hours/week) temporary assignment.

WHAT YOU'LL BE RESPONSIBLE FOR

• Ensures that prior authorization requests are completed in a manner that meets contractual requirements and that all prior authorization reviews are conducted using nationally recognized and evidence-based standards
• Participates in the Utilization Management (UM) Care Programs

WHAT YOU'LL NEED TO BE SUCCESSFUL

• Desirable Qualifications
  • Bachelor’s degree in Nursing
  • Working knowledge of managed care, the Medicare D-SNP and Medi-Cal programs, and related regulations
  • Working knowledge of Centers for Medicare & Medicaid Services (CMS) guidelines, including applicable Local Coverage Determinations and National Coverage Determinations
  • Working knowledge of Microsoft Excel and PowerPoint, and database software
  • Some knowledge of health care providers in the Alliance service area counties
  • Knowledge of:
    • Prior Authorization principles and practices
    • Principles and practices of clinical nursing
    • MCG Guidelines in review determination process
    • Medi-Cal program and related regulations and Title 22 regulations
  • Ability to:
    • Evaluate medical records and other health care data
    • Interpret, apply, and explain policies, regulations, terms, and procedures
    • Maintain organized and accurate records
  • Education and Experience:
    • Current unrestricted license as a Registered Nurse issued by the State of California
    • Associate’s degree in Nursing and a minimum of five years of experience in a patient care setting which included a minimum of one year of the required experience (a Bachelor’s degree may substitute for two years of the required experience); or an equivalent combination of education and experience may be qualifying

OTHER INFORMATION

• We are in a hybrid work environment and we anticipate that the interview process will take place remotely via Microsoft Teams.
• While some staff may work full telecommuting schedules, attendance at quarterly company-wide events or department meetings will be expected.
• In-office or in-community presence may be required for some positions and is dependent on business need. Details about this can be reviewed during the interview process.
• This is a temporary position and does not provide the benefits that are listed below (it is standard language from our regular job posts and cannot be altered or removed). Temporary employees on assignment at the Alliance will be connected to a staffing agency with separate benefit options.

COMPENSATION INFORMATION

• Zone 1 Pay Range: $52 - $57.50

  Typical areas in Zone 1: Santa Cruz, San Benito, and Monterey Counties, Bay Area, Sacramento, Los Angeles and San Diego areas

• Zone 2 Pay Range: $49- $54

  Typical areas in Zone 2: Mariposa and Merced Counties, Fresno area, Bakersfield, Eastern California, San Luis Obispo area, and the Central Valley (except Sacramento)

• The applicable salary ranges are based on work location and are aligned to a zone according to the cost of labor in your area. All ranges are subject to change in the future. We are happy to answer any questions that you have or share the applicable pay zone for your location if it’s not one of the typical areas listed. You can reach out to [e-mail], and a member from our Talent Acquisition team will be in touch.

• The posted hiring ranges represent a good‑faith estimate of what a temporary employee would be paid on this assignment. Final compensation will be determined by our compensation philosophy, analysis of the selected candidate's qualifications (direct or transferable experience related to the position, education, or training), as well as other factors (internal equity, market factors, and geographic location).

OUR BENEFITS

• Medical, Dental and Vision Plans
• Ample Paid Time Off
• 12 Paid Holidays per year
• 401(a) Retirement Plan
• 457 Deferred Compensation Plan
• Robust Health and Wellness Program
• Onsite EV Charging Stations
• And many more

ABOUT US

We are a group of over 500 dedicated employees, committed to our mission of providing accessible, quality health care that is guided by local innovation. We feel that our work is bigger than ourselves. We leave work each day knowing that we made a difference in the community around us.

The Alliance is an equal employment opportunity employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), sexual orientation, gender perception or identity, national origin, age, marital status, protected veteran status, or disability status. We are an E-Verify participating employer

Join us at Central California Alliance for Health (the Alliance) is an award‑winning regional Medi-Cal managed care plan that provides health insurance for children, adults, seniors and people with disabilities in Mariposa, Merced, San Benito and SantaCruze counties. We currently serve more than418,000 members. To learn more about us, take a look at our Fact Sheet.

At this time the Alliance does not provide any type of sponsorship. Applicants must be currently authorized to work in the United States on a full-time, ongoing basis without current or future needs for any type of employer supported or provided sponsorship.