Pre-Authorization Nurse LPN

MJHS; New Rochelle (NY); On-site; USD 55,000 - 75,000; Full time

Job summary

MJHS in New Rochelle, NY, seeks an experienced LPN to support utilization management for elective services and DME requests, ensuring compliance with Medicare guidelines.

The role collaborates with Care Managers and UM Coordinators to ensure timely admissions communications and proper authorizations.

Candidate should have NY LPN license, 1–3 years Medical/Surgical nursing experience, familiarity with Windows/Word/Excel, and strong communication and analytical skills.

Qualifications

• Licensed practical nurse in New York with current registration.
• Knowledge of Medicare/managed care processes preferred.
• Familiarity with utilization management concepts.

Responsibilities

• Process requests for elective services, out-of-network, out-of-area requests and durable medical equipment per criteria and Medicare guidelines.
• Communicate all elective hospital admissions to the Utilization Management Coordinator to ensure timely receipt of information and continuity of member care.
• Ensure that authorizations are appropriate, and determinations are made 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

Medical terminology

Education

LPN NY License

Tools

Windows

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.