Pre-Authorization Nurse LPN

MJHS; City of White Plains (NY); On-site; USD 34,000 - 52,000; Full time

Job summary

MJHS seeks a practical nurse (LPN) to process elective service requests, out-of-network/out-of-area requests, and durable medical equipment per Medicare guidelines. You will coordinate with the Utilization Management Coordinator and Care Manager to ensure timely information and continuity of member care.

Required are NY LPN licensure and 1–3 years of Medical/Surgical nursing experience, with preferred exposure to managed care and utilization management processes.

Qualifications

• Graduate of an accredited Practical Nursing Program; NY LPN license and registration required.
• Minimum 1–3 years Medical/Surgical nursing experience; managed care experience preferred.
• Familiarity with Utilization management processes; working knowledge of Windows, Word and Excel; strong communication & analytical skills.

Responsibilities

• Process requests for elective services, out of network requests, out of area requests and DME per Medicare guidelines.
• Communicate elective hospital admissions to the Utilization Management Coordinator and/or Care Manager to ensure 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-authorization, concurrent review and discharge planning.

Skills

Analytical abilities

Written and verbal communication

Windows/Excel skills

Education

Practical Nursing Program graduate

NY LPN license and registration

Tools

Windows OS

Microsoft Word

Microsoft 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.