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Prior Authorizations Nurse I - RN

Company: Central California Alliance for Health
Location: Merced
Posted on: October 1, 2019

Job Description:

We have an opening to join our Utilization Management/Prior Authorizations team as a Prior Authorizations Nurse I.

ABOUT USWe 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 over 330,000 members in Santa Cruz, Monterey and Merced counties. To learn more about us, click here or check out this video.

WHAT YOU'LL BE RESPONSIBLE FORReporting to the Utilization Management Supervisor for Prior Authorizations, you will ensuring 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.


Prior Authorization (PA) is the process by which physicians and other health care providers must obtain approval from a health plan for a specific procedure, service, device, supply or medication to be delivered to the patient to qualify for payment coverage. The ultimate purpose of the PA function at the Alliance is to optimize patient outcomes by ensuring that our members receive the most appropriate care available. Our PA team reviews provider requests using nationally recognized and evidence-based standards and ensures that these reviews are completed in a timely fashion to meet contractual requirements and promote the quick delivery of high quality care. Our team is comprised of RN's and LVN's who appreciate and respect one another and are always willing to share knowledge to promote learning and growth. We are a high-functioning team that recognizes and draws upon the strengths of each person in order to best serve Alliance members and providers. The work is high volume, fast-paced and we love what we do.


  • 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
      • Evaluate medical records and other health care data
      • Exercise good judgment and professional consideration with health care providers and beneficiaries

      • Education and Experience:

        • Current unrestricted license as a Registered Nurse issued by the State of California
        • Bachelor's degree in Nursing

        • 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 which would provide the required knowledge, skills and abilities may be qualifying

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

          OUR BENEFITS

          • Medical, Dental and Vision Plans
          • Ample Paid Time Off
          • 11 Paid Holidays per year
          • 401(a) Retirement Plan
          • 457 Deferred Compensation Plan
          • Robust Health and Wellness Program
          • EV Charging Stations
          • And many more

            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 sponsorship.

Keywords: Central California Alliance for Health, Merced , Prior Authorizations Nurse I - RN, Healthcare , Merced, California

Click here to apply!

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