Pre-Authorization Nurse LPN

MJHS; City of Mount Vernon (NY); Presencial; USD 55.000 - 75.000; Jornada completa

Descripción de la vacante

Elderplan and HomeFirst, our Medicare and Medicaid managed care health plans, are seeking a licensed practical nurse to support care coordination and pre-authorization processes in Mount Vernon, NY.

You will process requests, communicate hospital admissions to care managers, ensure proper authorizations, and apply program criteria to identify members for care management. Requires NY LPN license and 1–3 years of medical/surgical experience, with familiarity with Windows, Word and Excel.

Formación

• Graduate of an accredited Practical Nursing Program; NY LPN license and registration required.
• 1–3 years Medical/Surgical nursing experience.
• Familiarity with Utilization management processes.
• Working knowledge of Windows, Word and Excel.
• Excellent written and oral communication skills.

Responsabilidades

• Process requests for 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.

Conocimientos

Communication skills

Analytical abilities

Utilization management

Educación

LPN NY license

Herramientas

Windows

Word

Excel

Descripción del empleo

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.