Pre-Authorization Nurse LPN

MJHS; Town of Hempstead (NY); On-site; USD 55,000 - 75,000; Full time

Job summary

MJHS is seeking an LPN to support Elderplan and HomeFirst by processing elective service requests and coordinating with Utilization Management to ensure seamless patient care. The role requires an active NY LPN license, 1–3 years of Medical/Surgical experience, and familiarity with utilization management concepts.

Responsibilities include authorizing appropriate services, documenting determinations for claims, and participating in pre-authorization, concurrent review, and discharge planning for

Qualifications

• Graduate of an accredited Practical Nursing Program.
• Current LPN NY license and registration required.
• Minimum of 1-3 years Medical/Surgical nursing experience; managed care experience preferred.
• Familiarity with Utilization management processes and Windows/Excel.

Responsibilities

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

Medical/Surgical nursing experience

Utilization management knowledge

Communication skills

Windows & Excel familiarity

Education

Practical Nursing Program graduate

Tools

Microsoft 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.