Prior Authorization Review LPN

HealthCare Partners, IPA and HealthCare Partners, MSO together comprise our health care delivery system providing enhanced quality care to our members, providers and health plan partners. Active since 1996, HealthCare Partners (HCP) is the largest physician-owned and led IPA in the Northeast, serving the five boroughs and Long Island. Our network includes over 6,000 primary care physicians and specialists delivering services to our 125,000 members enrolled in Commercial, Medicare and Medicaid products. Our MSO employs 200+ skilled professionals dedicated to ensuring members have access to the highest quality of care while efficiently utilizing healthcare resources.

HCP’s vision is to be recognized by members, providers and payers as the organization that delivers unsurpassed excellence in healthcare to the people of New York and their communities. We pride ourselves on selecting the most qualified candidates who reflect HCP’s mission of serving our members by facilitating the delivery of quality care. Interested in joining our successful Garden City Team? We are currently seeking a Prior Authorization (PA) Nurse LPN!

Position Summary: The Prior Authorization (PA) Nurse LPN is responsible for reviewing and processing requests for medical services that require approval from insurance providers. The LPN evaluates the medical necessity, appropriateness, and documentation for requested services to ensure compliance with clinical guidelines, payer requirements, and regulatory standards. The role supports efficient authorization processing and contributes to optimal patient access to care. Responsibilities include review of requests for service authorizations in order to monitor continuity and coordination of care and to assist in the utilization of appropriate services. Assists with complex cases and internal process development. Interacts with the Utilization Management Care Management and Pharmacy Teams to direct appropriate utilization and data capture.

Essential Position Functions/Responsibilities:

• Determines compliance to pre-established medical necessity criteria applying payer-specific criteria (e.g., Medicare, Medicaid, commercial plans) and clinical guidelines to determine authorization eligibility.
• Identifies cases requiring potential or actual use of medically inappropriate interventions and refers to Medical Director for review.
• Coordinate with physicians, specialists, and facilities for missing documentation or clarifications
• Escalate complex cases to UM Manager or physician reviewer as required by protocol.
• Identify and report to Quality Management Department any potential quality of care issue and/or pre-established U.M. Referral Indicators.
• Document all authorization activities in the designated authorization platform.
• Ensure accurate entry of diagnosis codes, CPT/HCPCS codes, and clinical rationale.
• Maintain compliance with HIPAA and organizational privacy policies.
• Adhere to NCQA, URAC, CMS, and other applicable regulatory standards.
• Provide education to clinical staff regarding documentation requirements for PA approvals.
• Respond to health plan inquiries and requests , and report and submit all pertinent data in a timely manner.
• Collaborate with providers on alternatives for denied or non-covered services.
• Participate in quality assurance activities to improve PA workflows.
• Track and report on authorization turnaround times, approval/denial trends, and delays.
• Support audits and process improvement initiatives within the utilization management team.
• Actively participate in cross-departmental training to develop a deeper understanding of departmental operations and contribute to a more versatile team
• Performs other duties as directed by management.

Qualification Requirements:
Skills, Knowledge, Abilities

• Experience using MCG Criteria, National Coverage Determinations and Local Coverage Determinations
• Familiarity with ICD-10, and CPT coding.
• Understanding of payer policies and medical necessity criteria.
• Prior experience with EMR and PA systems (e.g., Epic, EZ-Net).
• Knowledgeable in MS Office Programs (i.e., Word, Excel, Outlook, Access and PowerPoint)

Skills :

• Excellent critical thinking and decision-making abilities.
• Strong written and verbal communication.
• Ability to multitask and prioritize in a fast-paced environment.
• Detail-oriented and organized with strong documentation practices.

Training/Education:

• Current NY State LPN license in good standing
• Graduate of an accredited LPN/LVN program.

Experience:

• 1–3 years of experience in utilization management, case management, insurance, or clinical nursing preferred.

Salary Information:
Annual Base Compensation: $70,000 - $85,000 per year
Bonus Incentive: Up to 5%, based on organizational performance

HealthCare Partners, MSO provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements, HealthCare Partners, MSO complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.