Prior Authorization Nurse (RN)

We have an opportunity to join the Alliance as a Prior Authorizations Nurse (RN) in Utilization Management. This position can be filled in any of our Alliance offices (Merced, Salinas or Scotts Valley). 

WHAT YOU'LL BE RESPONSIBLE FOR

Reporting to the Utilization Management Supervisor - Prior Authorizations (RN), you will ensure that prior authorization requests are completed in a timely fashion to meet contractual requirements and that all reviews are conducted using nationally recognized and evidence based standards

ABOUT THE TEAM

We determine medical necessity and benefit coverage for our members based on industry standards.

WHAT YOU'LL NEED TO BE SUCCESSFUL

To read the full position description, and list of requirements click here.

• Knowledge of:
  • Milliman Care Guidelines in review determination process
  • Medi-Cal and related policy and Title 22 regulations
  • Utilization management principles and activities
  • Case management principles and activities
• Ability to:
  • Understand concepts pertaining to prepaid health care
  • Demonstrate strong critical thinking and clinical nursing skills
  • Ability to evaluate medical records and other health care data
• Education and Experience:
  • Current unrestricted license as a Registered Nurse issued by the State of California
  • Bachelor’s degree in Nursing and a minimum of three years of experience in a patient care setting which included a minimum of one year of experience in Utilization Management or Case Management; 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.

The full compensation range for this position is listed by location below. 

The actual compensation for this role will be determined by our compensation philosophy, analysis of the selected candidate's qualifications (direct or transferrable experience related to the position, education or training), as well as other factors (internal equity, market factors, and geographic location).

Typical areas in Zone 1: Bay Area, Sacramento, Los Angeles area, San Diego area

Typical areas in Zone 2: Fresno area, Bakersfield, Central Valley (with the exception of Sacramento), Eastern California, Eureka area

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-profit 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.