Pre-Authorization Nurse LPN

MJHS; Bayonne (NJ); On-site; USD 55,000 - 75,000; Full time

Job summary

MJHS in Bayonne, NJ seeks a Practical Nurse (LPN) to support managed care operations within Elderplan and HomeFirst. You will process requests for elective services, out-of-network and out-of-area approvals, and durable medical equipment according to criteria and Medicare guidelines.

The role requires an accredited Practical Nursing program graduate, an active NY LPN license, 1–3 years Medical/Surgical nursing experience, and familiarity with utilization management.

Qualifications

• Graduate of an accredited Practical Nursing Program.
• Current NY LPN license and registration required.
• 1–3 years Medical/Surgical nursing experience; managed care preferred.
• Familiarity with Utilization management processes preferred.
• Working knowledge of Windows, Word and Excel.
• Knowledge of current standards of medical practice and healthcare delivery systems.
• Excellent written and oral communication skills.
• Good analytical abilities.

Responsibilities

• Process requests for elective services, out of network requests, out of area requests and durable medical equipment per criteria and Medicare guidelines.
• Communicate elective hospital admissions to Utilization Management Coordinator or Care Manager for timely information and continuity of member care.
• Ensure authorizations are appropriate and determinations documented to facilitate claims processing and data integrity.
• Apply program criteria to identify members for Care Management and Geriatric Case Management during pre-auth, concurrent review, and discharge planning.

Skills

Analytical abilities

Excellent communication skills

Windows

Word

Excel

Education

Accredited Practical Nursing Program

Active NY LPN license

Tools

Windows

Word

Excel

Job description

The challenges of affordable healthcare continue to create new opportunities. Elderplan and HomeFirst, our Medicare and Medicaid managed care health plans, are outstanding examples of how we are expanding services in response to our patients' and members' needs. These high-quality healthcare plans are designed to help keep people independent and living life on their own terms.

Process requests for selected elective services, out of network requests, out of area requests and durable medical equipment in accordance with departmental criteria, regulatory standards, and Medicare guidelines.

Communicates all elective hospital admissions to the appropriate Utilization Management Coordinator and/or Care Manager to ensure timely receipt of information and continuity of member care.

Ensures that authorizations are appropriate, and determinations are made and documented to facilitate claims processing, integrity of data record, and to minimize unnecessary retrospective review.

Applies program criteria to identify members for Care Management and Geriatric Case Management during the pre-authorization, concurrent review, and discharge planning process.

Graduate of an accredited Practical Nursing Program; current LPN NY license and registration required. Minimum of 1-3 years Medical/Surgical nursing experience; prior managed care experience preferred; familiarity with Utilization management processes preferred. Working knowledge of Windows, Word and Excel. Knowledge of current standards of medical practice and healthcare delivery systems. Excellent written and oral communication skills. Good analytical abilities.