Pre-Authorization RN

Metropolitan Jewish Health System; New York (NY); On-site; USD 85,000 - 110,000; Full time

Job summary

Metropolitan Jewish Health System seeks a registered nurse to coordinate utilization management and care planning for Medicare/Medicaid members in a long-term care context. You will work with Care Managers, Assessment Nurses, and physicians to ensure timely, compliant services and accurate patient records.

The role emphasizes interdisciplinary collaboration, strong assessment abilities, and knowledge of Medicare and Medicaid requirements, supporting patient independence and quality of life.

Qualifications

• Graduate of an accredited nursing program; Bachelor's preferred.
• Current NY RN license and registration required.
• CCM preferred; experience in long term care, managed care, home care, geriatrics or hospice.
• Knowledge of Medicare and NYS Medicaid guidelines and utilization management processes.

Responsibilities

• Process all requests for services per Medicare and NYS Medicaid guidelines.
• Collaborate with Care Manager, Assessment Nurse, and PCP or Specialists to ensure timely services.
• Coordinate timely UAS NY assessments reflecting member condition.
• Ensure Individualized Person-Centered Care Plan is updated and accurate.

Skills

InterQual knowledge

Utilization management

Assessment skills

Care coordination

Team collaboration

Education

Nursing degree

RN license NY

Bachelor's degree preferred

CCM preferred

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. Even in a non-clinical role, employees have an opportunity to make a positive impact on the quality of our health plan members' lives.

Processes all requests for services in accordance with Medicare and NYS Medicaid Guidelines as well as departmental criteria and guidelines. Works collaboratively with other disciplines including Care Manager, Assessment Nurse and Primary Care Physician or other Specialists as necessary to ensure timely provision of services. Coordinates timely completion of UAS NY assessment that accurately reflects current condition of the member. Ensures that the member's Individualized Person-Centered Care Plan has been updated and accurately reflects present status of the member.

• Graduate of an accredited nursing program, Bachelor's preferred
• Knowledge with Utilization management processes preferred
• Current NY RN license and registration required
• CCM preferred
• Minimum three to five years nursing experience in long term care, managed care, home care, geriatrics or hospice
• Prior experience in an interdisciplinary service delivery environment preferred
• Working knowledge of Medicare and Medicaid regulations
• Prior experience in an interdisciplinary service delivery environment preferred
• Working knowledge of Windows, Word and Excel
• Knowledge of current standards of medical practice and healthcare delivery systems
• Strong assessment skills
• Knowledge of Interqual preferred