Pre-Authorization Nurse LPN

MJHS; Village of Mineola (NY); On-site; USD 54,000 - 66,000; Full time

Job summary

MJHS is seeking a licensed Practical Nurse to process elective service requests, assist with utilization management, and support care coordination for Medicare/Medicaid populations in a managed care setting.

The role emphasizes accurate authorization determinations, data integrity, and collaboration with Care Managers during pre-authorization, concurrent review, and discharge planning.

Qualifications

• Graduate of an accredited Practical Nursing Program and NY LPN license.

Responsibilities

• Process requests for elective services, out-of-network requests, out-of-area requests and durable medical equipment per criteria.

Skills

Utilization management

Care management

Analytical skills

Written and oral communication

Microsoft Windows/Word/Excel

Education

Practical Nursing Program

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.