Pre-Authorization Nurse LPN

MJHS; Jersey City (NJ); On-site; USD 55,000 - 70,000; Full time

Job summary

MJHS in Jersey City is seeking a Licensed Practical Nurse (LPN) to support utilization management and case coordination for Medicare/Medicaid plans. The role focuses on processing requests, authorizations, and ensuring timely communication among care teams to maintain member care continuity.

The ideal candidate has an accredited Practical Nursing Diploma, an active LPN license, 1–3 years of Medical/Surgical nursing, familiarity with utilization management, and strong written and verbal

Qualifications

• Graduate of an accredited Practical Nursing Program.
• Current LPN license and registration.
• 1–3 years Medical/Surgical nursing experience.
• Familiarity with Utilization management processes.
• Proficient in Windows, Word and Excel.
• Excellent written and oral communication.

Responsibilities

• Process requests for elective services, out of network/out of area requests and durable medical equipment per criteria.
• Communicate elective hospital admissions to the Utilization Management Coordinator to ensure timely information and continuity of member care.
• Ensure that authorizations are appropriate and documented to facilitate claims processing and data integrity.
• Apply program criteria to identify members for Care Management during pre-authorization, concurrent review, and discharge planning.

Skills

Communication skills

Analytical abilities

Utilization management

Oral and written communication

Education

Licensed Practical Nurse (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.