Pre-Authorization Nurse LPN

MJHS; Village of Garden City (NY); Presencial; USD 52.000 - 72.000; Jornada completa

Descripción de la vacante

MJHS seeks a Licensed Practical Nurse (LPN) to support Elderplan and HomeFirst patients within a managed care framework. You will process elective service requests and pre-authorizations while ensuring compliance with Medicare guidelines and care coordination protocols.

Responsibilities include communicating admissions to care managers, documenting determinations, and assisting in discharge planning. Experience in medical/surgical nursing and familiarity with utilization management are preferred.

Formación

• Graduate of an accredited Practical Nursing Program.
• Current LPN NY license and registration required.
• Minimum 1–3 years Medical/Surgical nursing experience; prior managed care preferred.

Responsabilidades

• Process requests for elective services, out-of-network and out-of-area requests and durable medical equipment per criteria and Medicare guidelines.
• Communicate all elective hospital admissions to Utilization Management Coordinator/Care Manager for timely information and continuity of member care.
• Ensure authorizations are appropriate and determinations are documented to facilitate claims processing and data integrity.
• Apply program criteria to identify members for Care Management and Geriatric Case Management during pre-authorization, concurrent review, and discharge planning.

Conocimientos

Case management

Regulatory knowledge

Communication

Analytical abilities

Educación

LPN NY license

Herramientas

Windows

Word

Excel

Descripción del empleo

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.