Utilization Management Nurse (RN) (Temporary)

Central California Alliance for Health; California (MO); On-site; USD 108,000 - 119,000; Full time

Benefits offered by this job

Medical, Dental and Vision Plans

Ample Paid Time Off

12 Paid Holidays per year

401(a) Retirement Plan

457 Deferred Compensation Plan

Health and Wellness Program

Onsite EV Charging Stations

Job summary

Central California Alliance for Health is seeking a Registered Nurse for a temporary, full-time Utilization Management role. The position involves reviewing prior authorizations, performing concurrent and retrospective reviews, and participating in UM Care Programs to support optimal patient care.

Desirable qualifications include a California RN license, knowledge of CMS guidelines, and experience with Excel/PowerPoint. Hybrid work is expected with potential remote interview steps.

Qualifications

• Bachelor’s degree in Nursing required; RN license in California.
• Experience with Utilization Management or Case Management preferred.
• Knowledge of CMS guidelines and Medicare/Medicaid rules.
• Familiarity with Excel, PowerPoint and data tools.
• Ability to evaluate medical records and apply policies consistently.

Responsibilities

• Ensure prior authorizations meet contractual requirements using evidence-based standards.
• Conduct concurrent or retrospective reviews of acute in-patient services.
• Participate in Utilization Management Care Programs and related processes.

Skills

Managed care knowledge

CMS guidelines understanding

Excel & PowerPoint

Data interpretation

Education

Bachelor’s degree in Nursing

Associate’s degree in Nursing

Tools

Microsoft Excel

PowerPoint

Database software

Job description

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 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
• Performs concurrent or post-service (retrospective) review of acute in-patient care services using established criteria
• 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: Utilization Management, and/or Case Management 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 experience in Utilization Management or Case Management (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

Available for all regular Alliance employees working more than 30 hours per week. Some benefits are available on a pro-rated basis for part-time employees. These benefits are unavailable to temporary employees while on an assignment with the Alliance.

• 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

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.

Join us at Central California Alliance for Health (the Alliance), where you will be part of a culture that is respectful, diverse, professional and fun, and where you are empowered to do your best work. As a regional non-profits health plan, we serve members in Mariposa, Merced, Monterey, San Benito and Santa Cruz counties. To learn more about us, take a look at our Fact Sheet . 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. 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.