Contractual Prior Authorization Rn Jobs in California

Organization

Opsam Health

Position Type

Full-Time ONSITE Position

Reports To

Chief Medical Officer / Clinical Leadership

Salary Range

$74,880 - $95,680 annually, depending on experience

• Triage incoming patient calls, portal messages, and clinical concerns using nursing judgment, approved triage protocols, and Opsam Health policies.
• Assess patient symptoms, identify urgent or emergent conditions, and direct patients to the appropriate level of care, including same-day appointment, provider review, urgent care, emergency department, or 911 when indicated.
• Document all triage encounters accurately and timely in the electronic medical record, including assessment, disposition, education provided, escalation, and follow-up plan.
• Provide patient education and self-care instructions within RN scope of practice and approved protocols.
• Escalate clinical concerns to providers, site leadership, or clinical leadership when symptoms, risks, or patient needs require additional review.
• Assist providers and clinic teams with EMR messages, telephone encounters, clinical task management, and patient follow-up.
• Support medication refill workflows by reviewing refill requests, gathering relevant clinical information, checking protocol criteria, identifying safety concerns, and routing requests appropriately.
• Assist with prior authorization tasks by collecting clinical documentation, supporting medication or service authorization requests, and communicating with providers, pharmacies, referral staff, and payers as needed.
• Follow up with patients regarding lab results, imaging results, medication issues, care instructions, and provider recommendations as assigned and within scope.
• Coordinate with care teams to support chronic disease management, preventive care, transitions of care, and patient access.
• Recognize high-risk situations, including abnormal symptoms, medication safety concerns, behavioral health concerns, and barriers to care.
• Maintain patient confidentiality and comply with HIPAA, FQHC requirements, nursing standards, and Opsam Health compliance expectations.
• Provide limited in-clinic nursing support when needed, including patient assessment, clinical procedures within RN scope, vaccine or medication-related support, and provider assistance.
• Participate in quality improvement, patient safety, access improvement, and workflow standardization efforts.
• Communicate with patients in a professional, respectful, culturally sensitive, and patient-centered manner.
• Follow all Opsam Health policies, procedures, standing orders, triage protocols, refill protocols, documentation standards, and escalation workflows.
• Perform other clinical duties as assigned to support safe and effective clinic operations.

• Active and unrestricted California Registered Nurse license.
• Minimum of 3 to 5 years of recent experience in telephone triage, ambulatory care, outpatient clinic, urgent care, emergency department, primary care, or similar clinical setting.
• Strong clinical assessment and critical thinking skills.
• Ability to identify urgent and emergent symptoms and take appropriate action.
• Experience using an electronic medical record system.
• Excellent verbal and written communication skills.
• Strong documentation, organization, and follow-through skills.
• Ability to work independently while collaborating with providers and care teams.
• Professional telephone etiquette and strong customer service skills.
• Ability to remain calm, respectful, and effective when handling difficult or urgent patient situations.
• Knowledge of nursing scope of practice, patient confidentiality, and healthcare compliance expectations.

• Experience working in a Federally Qualified Health Center, community health center, or safety-net outpatient setting.
• Experience with eClinicalWorks or similar EMR.
• Experience with medication refill protocols, prior authorization workflows, referrals, and managed care processes.
• Bilingual ability preferred, especially in languages commonly spoken by Opsam Health patients.
• Experience working with Medi-Cal, Medicare, uninsured, and medically underserved populations.
• Familiarity with chronic disease management, preventive care measures, and team-based care.

• Sound nursing judgment and ability to make timely clinical decisions.
• Strong ability to prioritize multiple patient needs and clinical tasks.
• Ability to clearly explain care instructions to patients with varying levels of health literacy.
• Ability to work effectively with providers, medical assistants, front office staff, care coordinators, pharmacies, and external partners.
• Strong attention to detail when documenting, routing, and following up on clinical concerns.
• Commitment to patient safety, access to care, and high-quality service.
• Understanding of culturally responsive care in a diverse and multilingual patient population.
• Ability to follow standardized protocols while recognizing when provider escalation is needed.