Pre-Authorization Nurse LPN

MJHS; Passaic (NJ); On-site; USD 65,000 - 75,000; Full time

Job summary

MJHS in New Jersey, including Elderplan and HomeFirst, seeks an experienced Licensed Practical Nurse to support utilization management and care coordination for Medicare/Medicaid plans.

Graduate of an accredited Practical Nursing Program; NY license and registration required. 1–3 years of Medical/Surgical nursing is expected; prior managed care experience preferred; familiarity with utilization management processes is a plus. Strong communication and analytical skills are essential.

Qualifications

• Graduate of an accredited Practical Nursing Program; current LPN NY license and registration required.
• 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.
• Excellent written and oral communication skills; good analytical abilities.

Responsibilities

• Process requests for selected elective services, out of network/out of area requests and durable medical equipment per criteria.
• Communicate elective hospital admissions to Utilization Management Coordinator/Care Manager for continuity of care.
• Ensure authorizations are appropriate and documented to facilitate claims processing and data integrity.
• Apply program criteria to identify members for Care Management and Geriatric Case Management during care cycles.

Skills

Communication skills

Analytical abilities

Utilization management familiarity

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.