Pre-Authorization Nurse LPN

MJHS; Union City (NJ); On-site; USD 50,000 - 65,000; Full time

Job summary

MJHS, serving Elderplan and HomeFirst, is seeking a Practical Nurse (LPN) to support managed care nursing operations. The role processes requests for elective services, out-of-network and out-of-area approvals, and durable medical equipment per criteria.

Graduate of an accredited Practical Nursing Program with a current NY license. 1–3 years Medical/Surgical experience; familiarity with utilization management preferred.

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.
• Good analytical abilities.

Responsibilities

• Process requests for 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.

Skills

Communication skills

Analytical abilities

Utilization management familiarity

Windows

Word

Excel

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.