Utilization Management Nurse (RN) (Temporary)

We give priority to applicants who live in or near our service counties: Santa Cruz, Monterey, Merced, San Benito, and Mariposa.

About the role

This is a temporary, full-time (40 hours/week) assignment estimated to run from August to December 2026, dependent on business need. You will be employed by a temporary employment agency that we will connect you with if hired for this position.

This is a hybrid role. While interviews will be conducted remotely via Microsoft Teams, attendance at quarterly company-wide events or department meetings will be expected. In-office or in-community presence may be required depending on business need.

Responsibilities

• Ensure prior authorization requests are completed in a manner that meets contractual requirements, using nationally recognized and evidence-based standards.
• Perform concurrent or post-service (retrospective) review of acute in-patient care services using established criteria.
• Participate 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, 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.

Qualifications

• Bachelor’s degree in Nursing (desirable).
• 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 the 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.

Pay

Compensation is based on work location and aligned to a zone according to the cost of labor in your area. Final compensation will be determined by qualifications, internal equity, market factors, and geographic location.

• Zone 1 Pay Range: $52 - $57.50 per hour
  Typical areas: Santa Cruz, San Benito, Monterey Counties, Bay Area, Sacramento, Los Angeles, and San Diego areas.
• Zone 2 Pay Range: $49 - $54 per hour
  Typical areas: Mariposa and Merced Counties, Fresno area, Bakersfield, Eastern California, San Luis Obispo area, and the Central Valley (except Sacramento).

About Us

We are a regional non-profit health plan serving members in Mariposa, Merced, Monterey, San Benito, and Santa Cruz counties. Our team of over 500 employees is committed to providing accessible, quality health care guided by local innovation. We foster a respectful, diverse, professional, and fun culture where employees are empowered to do their best work.