Utilization Management Nurse

Remote in California OUR COMMITMENT TO A HUMAN HIRING PROCESS We believe every candidate deserves thoughtful consideration.That’swhy we do not use AI or automated systems toreview applications . Every application is reviewed bya 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 Reporting to the Utilization Management Supervisor, this position: 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 experie nce in Utilization Management or Case M anagement (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 View email address on click.appcast.io , 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-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 ourFact 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. #J-18808-Ljbffr