Pre-Authorization Nurse LPN

MJHS; Village of Great Neck (NY); On-site; USD 55,000 - 75,000; Full time

Job summary

MJHS seeks an experienced Licensed Practical Nurse (LPN) for our Medicare/Medicaid managed care teams in the New York area. The role focuses on pre-authorization, utilization management, and discharge planning to support member care continuity.

Candidates should have NY LPN licensure, 1–3 years of Medical/Surgical nursing experience, and familiarity with Windows, Word and Excel. Managed care exposure is preferred to optimize care delivery.

Qualifications

• Licensed Practical Nurse (LPN) in New York with current license and registration.
• 1–3 years of Medical/Surgical nursing experience; managed care experience preferred.
• Working knowledge of Windows, Word and Excel; familiarity with utilization management processes.

Responsibilities

• Process requests for elective services, out of network, out of area and durable medical equipment per criteria and Medicare guidelines.
• Communicate all elective hospital admissions to Utilization Management Coordinator and Care Manager for continuity of member 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 pre-authorization, concurrent review, and discharge planning.

Skills

Analytical abilities

Written and verbal communication

Healthcare delivery systems knowledge

Education

LPN NY license

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.