Impress employers and recruiters.
Choose from hundreds of resume examples.

Impress employers and recruiters.
Choose from hundreds of resume examples.

Target Resume Now

About the Role

Elderplan and HomeFirst are Medicare and Medicaid managed care health plans that provide high-quality healthcare designed to help people live independently. MJHS is a supportive community committed to excellence, respect, and personalized healthcare services.

Responsibilities

• Provides oversight of the Pre-Authorization unit to ensure regulatory compliance for timeframes and notification parameters through ongoing monitoring.
• Develops and directs oversight of all MLTC/MAP organization determination/authorization processes to ensure timeliness and compliance with CMS/DOH regulations.
• Collaborates in the development of goals, objectives, and performance measures for the Coordinated Care Department.
• Reviews and revises all workflows and policies for the Pre-Authorization unit annually to ensure compliance with DOH and CMS regulations.
• Ensures Interqual, internal policies, and other criteria are applied consistently among staff through daily monitoring and review of service requests.
• Educates staff on any changes to criteria/policy and discusses the need for additional medical policy with the Director when gaps are noted.
• Conducts periodic focused medical records reviews for the Pre-Authorization unit using department-specific audit tools and provides additional education.
• Analyzes collected audit data and reports findings to Coordinated Care management.
• Works with the Staff Educator on re-training efforts either on-site or through webinar sessions.

Requirements

• Minimum of 5 years of experience in utilization review or pre-authorization.
• Experience in a managed care environment.
• Knowledge of CMS and DOH regulations.
• Familiarity with Interqual criteria.

Skills

• Leadership
• Oversight
• Regulatory Compliance
• Process Improvement
• Auditing
• Medical Records Review
• Staff Education
• Data Analysis
• Communication

Location

• New York, NY

Work Type

• Full-time

Experience Level

• 5+ years

Education Level

• Bachelor's degree in Nursing or related field preferred.

Salary/Compensations

• USD $135,000.00/Yr. - USD $150,000.00/Yr.

Benefits

• 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
• Two retirement plans: 403(b) AND Employer Paid Pension
• Flexible spending
• Qualified employer under the Federal Government’s Paid Student Loan Forgiveness Program (PSLF)

About the Company

• MJHS is 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.

Equal Opportunity

• MJHS companies are qualified employers under the Federal Government’s Paid Student Loan Forgiveness Program (PSLF)