Pre-Authorization Nurse LPN

MJHS; Clifton (NJ); On-site; USD 52,000 - 68,000; Full time

Job summary

MJHS is seeking a qualified Licensed Practical Nurse in New Jersey to support our Elderplan/HomeFirst care management initiatives. You will process requests for elective services, out-of-network and out-of-area requests, and durable medical equipment while adhering to departmental criteria, regulatory standards, and Medicare guidelines.

As part of the utilization management team, you will communicate hospital admissions to the UM Coordinator or Care Manager to ensure continuity of care, verify

Qualifications

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

Responsibilities

• Process requests for elective services, out-of-network and out-of-area requests, and equipment per criteria.
• Communicates elective hospital admissions to the Utilization Management Coordinator or Care Manager.
• Ensure authorizations are appropriate and determinations documented to support claims processing.
• Identify members for Care Management during pre-authorization, concurrent review, and discharge planning.

Skills

Excellent written and oral comms

Good analytical abilities

Windows, Word and Excel

Education

Graduate of an accredited Practical Nursing Program

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.