Prior Authorizations Nurse - Registered Nurse
About the job
- An Associate’s degree in Nursing and at least five years of experience in a patient care setting, including at least 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 qualify.
- A current unrestricted Registered Nurse license issued by the State of California.
- Working knowledge of managed care, the Medicare D-SNP and Medi-Cal programs, and related regulations.
- Working knowledge of Centers for Medicare & Medicaid Services guidelines, including applicable Local Coverage Determinations and National Coverage Determinations.
- Working knowledge of Microsoft Excel, 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 clinical nursing principles and practices.
- Knowledge of MCG Guidelines in the review determination process.
- Knowledge of the Medi-Cal program and related regulations, including 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.
- Ensure prior authorization requests are completed in a manner that meets contractual requirements and that prior authorization reviews use nationally recognized and evidence-based standards.
- Participate in the Utilization Management Care Programs.
- Bachelor’s degree in Nursing.
About the company
A regional Medi-Cal plan that serves over 434,000 members across Mariposa, Merced, Monterey, San Benito, and Santa Cruz counties. It enrolls members in a Medi-Cal plan and coordinates care through a network of primary care physicians and clinics to focus on preventive care and ongoing management, rather than paying for care on a fee-for-service basis. The plan distinguishes itself with a mission-focused effort to improve access for low-income residents, a history dating back to 1996, and a broad, community-oriented regional footprint. Its goal is to achieve Healthy People. Healthy Communities by improving health outcomes and access to care for the communities it serves.
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Simplify's Take
What believers are saying
- Alliance launched a $20 million 2026 Medi-Cal Capacity Grant Program.
- September 2026 Member Outreach and Retention grants target enrollment stability and retention.
- TotalCare launched in 2026, creating a Medicare D-SNP growth channel.
What critics are saying
- January 1, 2027 Medi-Cal fee-for-service transfers shrink Alliance membership and revenue.
- NCQA reports a 2.5-star Medicaid rating, weakening recruiting, contracting, and member perception.
- TotalCare had roughly 965 members in 2026, leaving Medicare diversification negligible.
What makes Central California Alliance for Health unique
- Five-county Medi-Cal dominance in Mariposa, Merced, Monterey, San Benito, and Santa Cruz counties.
- Thirty years operating locally, with $44.9 million invested in 2025 community infrastructure.
- NCQA accredited in 2026 for Health Plan and Health Equity, signaling operational maturity.
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Benefits
- Health Insurance
- Dental Insurance
- Vision Insurance
- 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