Pre-Authorization Nurse LPN

MJHS; Hoboken (NJ); On-site; USD 55,000 - 75,000; Full time

Job summary

MJHS seeks an experienced Licensed Practical Nurse to process requests for elective services and DME in line with Medicare guidelines. The role requires coordination with Utilization Management and Care Managers to ensure timely, continuous member care.

You will verify authorizations to support accurate claims processing and data integrity. Graduate of an accredited Practical Nursing Program with an active LPN license (NY) and 1–3 years of Medical/Surgical nursing experience.

Qualifications

• Graduate of an accredited Practical Nursing Program.
• Current LPN NY license and registration required.
• 1–3 years Medical/Surgical nursing experience; managed care preferred.

Responsibilities

• Process requests for elective services, out of network and durable medical equipment per criteria and Medicare guidelines.
• Communicate admissions and care plan details to Utilization Management and Care Managers.
• Ensure authorizations and determinations support claims processing and data integrity.
• Apply program criteria to identify members for Care Management and Geriatric Case Management.

Skills

LPN license

Medical/Surgical nursing

Managed care

Utilization management

Communication skills

Analytical ability

Education

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.