RN - Prior Authorization Specialist (Hybrid)

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

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.