Pre-Authorization Nurse LPN

MJHS; City of Yonkers (NY); Presencial; USD 60.000 - 75.000; Jornada completa

Descripción de la vacante

MJHS seeks a Licensed Practical Nurse to process elective service requests, out-of-network/out-of-area requests, and durable medical equipment per policy and Medicare guidelines.

The role collaborates with Utilization Management to ensure timely admissions information and proper pre-authorization, discharge planning, and care coordination for members.

Formación

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

Responsabilidades

• Process requests for selected elective services and equipment per criteria.
• Communicate hospital admissions to Utilization Management/Care Manager.
• Ensure authorizations are appropriate to support claims processing.
• Apply program criteria for Care Management during pre-authorization, concurrent review, and discharge planning.

Conocimientos

Communication skills

Analytical abilities

Nursing clinical knowledge

Utilization management

Educación

Practical Nursing Program

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.