About the position
This is a temporary, full-time (40 hours/week) assignment estimated to last from August to December 2026, dependent on business needs. While working for the Alliance, the employee will be hired through a temporary employment agency. The position focuses on ensuring prior authorization requests meet contractual requirements and are reviewed using nationally recognized, evidence-based standards. It also involves performing concurrent or post-service reviews of acute in-patient care services and participating in Utilization Management (UM) Care Programs.
Responsibilities
• 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
Requirements
• 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
• 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
• 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
• Ability to interpret, apply, and explain policies, regulations, terms, and procedures
• Ability to maintain organized and accurate records
Nice-to-haves
• Bachelor’s degree in Nursing
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