Pre-Authorization Nurse LPN

MJHS; Newark (NJ); On-site; USD 60,000 - 75,000; Full time

Job summary

MJHS in Newark is seeking a licensed practical nurse (LPN) to support Medicare and Medicaid plans through pre-authorization, concurrent review, and discharge planning. You will process service requests, coordinate with care managers, and help ensure accurate authorizations and data integrity.

Candidate should have 1–3 years of Medical/Surgical nursing experience, familiarity with utilization management, and current LPN licensure in New York.

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.
• Working knowledge of Windows, Word and Excel.

Responsibilities

• Process requests for elective services, out of network requests, out of area requests and durable medical equipment.
• Communicate all elective hospital admissions to Utilization Management Coordinator or Care Manager.
• Ensure authorizations are appropriate and determinations are documented to facilitate claims processing.
• Apply program criteria to identify members for Care Management and Geriatric Case Management during pre-authorization, concurrent review, and discharge planning.
• Maintain high standards of data integrity and compliance with regulatory guidelines.

Skills

Communication skills

Analytical abilities

Utilization management knowledge

Nursing experience

Windows/Word/Excel

Education

Practical Nursing Program

New York license and registration

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.