Prior Authorizations Nurse (RN) (Temporary)

The role

The Prior Authorizations Nurse ensures prior authorization requests meet contractual requirements and uses evidence-based standards. This person also participates in Utilization Management Care Programs.

What you will do

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

Required qualifications

• 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 Bac
• or an equivalent combination of education and experience

Nice to have

• 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
• Knowledge of Principles and practices of clinical nursing
• Knowledge of MCG Guidelines in review determination process
• Knowledge of Medi-Cal program and related regulations and Title 22 regulations
• Ability to evaluate medical records and other health care data

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

Before you apply

• 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
• The Alliance does not provide any type of sponsorship

About the company

Central California Alliance for Health (the Alliance) is a regional Medi-Cal managed care plan providing health insurance for children, adults, seniors and people with disabilities in Mariposa, Merced, San Benito and Santa Cruz counties.