jobs in Jersey City, NJ

Nursing Jobs in Jersey City, NJ

Pre-Authorization Unit Manager

Overview 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. The MJHS Difference At MJHS, we are more than a workplace; we are a supportive community committed to excellence, respect, and providing high-quality, personalized health care services. We foster collaboration, celebrate achievements, and promote fairness for all. Our contributions are recognized with comprehensive compensation and benefits, career development, and the opportunity for a healthy work-life balance, advancement within our organization and the fulfillment of having a lasting impact on the communities we serve. Benefits include: Sign-on Bonuses OR Student Loan Assistance for clinical staff Free MSN in Education program! Tuition Reimbursement for all full and part-time staff Dependent Tuition Reimbursement for clinical staff! Generous paid time off, including your birthday! Affordable and comprehensive medical, dental and vision coverage for employee and family members Two retirement plans ! 403(b) AND Employer Paid Pension Flexible spending And MORE! MJHS companies are qualified employers under the Federal Government’s Paid Student Loan Forgiveness Program (PSLF) Responsibilities Provides oversight of Pre-Authorization unit to ensure all organization determinations are within regulatory compliance for time frames and notification parameters through ongoing monitoring of the unit’s activity. Development and direct oversight of all MLTC/MAP organization determination/authorization processes to ensure timeliness and compliance with CMS/DOH regulations. Collaborates in development of goals, objectives and performance measures and outcomes for the Coordinated Care Department. Reviews/Revises all workflows and policies for the Pre-Authorization unit on at least annual basis to ensure compliance with DOH and CMS regulations. Communicates changes required for compliance within and outside of Coordinated Care Department, including Member Operations, Customer Service, Claims, Compliance, and Appeals and Grievances departments. Ensures Interqual (IQ), interal policies and other criteria (NYS DOH, NCD, LCD) are applied consistently among staff through daily monitoring and review of the requests for services assigned to the unit. Educates staff on any changes to criteria/policy. Discusses with Director, the need for additional medical policy when gaps in coverage criteria are noted. Conducts periodic focused medical records reviews for Pre-Authorization unit by using department specific audit tools and provides additional education as needed. Analyzes combined collected audit data and reports findings to Coordinated Care management. Works with Staff Educator on re-training efforts either on site or through Webinar sessions. Min USD $135,000.00/Yr. Max USD $150,000.00/Yr.