Pre-Authorization Nurse LPN

MJHS; Fort Lee (NJ); On-site; USD 52,000 - 70,000; Full time

Job summary

MJHS is seeking an experienced Licensed Practical Nurse (LPN) to support Elderplan and HomeFirst initiatives in an ambulatory or managed care setting. The role focuses on pre-authorization, utilization management, and discharge planning to ensure continuity of member care.

Graduate of an accredited Practical Nursing Program with NY LPN licensure is required, plus 1–3 years of Medical/Surgical nursing experience.

Qualifications

• 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.

Responsibilities

• 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.

Skills

Medical/Surgical nursing

Utilization management

Managed care experience

Windows

Word

Excel

Communication skills

Analytical abilities

Education

Practical Nursing Program (LPN)

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.