LPN Utilization Management Nurse

Integra Partners Holdings, Inc.; United States; Remote; USD 65,000 - 95,000; Full time

Job summary

Integra Partners Holdings, Inc. is seeking a full-time remote LPN Utilization Management Nurse to perform pre-service and post-service utilization reviews for DMEPOS, ensuring NCQA standards and medical necessity criteria.

The role collaborates with the Medical Director to review authorizations, communicate outcomes, and support appeals. It requires strong UM experience in managed care and familiarity with InterQual and CMS guidelines.

Qualifications

• Active LPN or LVN license
• Minimum 3 years of nursing experience in acute or outpatient settings
• At least 2 years of utilization management experience in managed care
• Familiarity with medical necessity criteria (InterQual, CMS)
• Experience with UM authorizations and appeals for DMEPOS is highly desirable

Responsibilities

• Conduct pre-service and post-service UM authorization reviews based on federal and state mandates and benefit language
• Communicate outcomes of UM authorization reviews and process administrative and clinical appeals as needed
• Maintain compliance with accrediting agency standards and collaborate with non-clinical teams to gather necessary clinical information

Skills

UM nursing experience

LPN/LVN license

CMS/InterQual familiarity

DMEPOS knowledge

Job description

Job Summary

Collaborating with the Medical Director, the full-time remote LPN Utilization Management Nurse will perform pre-service and post-service utilization reviews and appeals for DMEPOS, ensuring compliance with NCQA standards and medical necessity criteria.

Key responsibilities

• Conduct pre-service and post-service UM authorization reviews based on federal and state mandates and benefit language
• Communicate outcomes of UM authorization reviews and process administrative and clinical appeals as needed
• Maintain compliance with accrediting agency standards and collaborate with non-clinical teams to gather necessary clinical information

Required qualifications

• Active Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) license
• Minimum of 3 years of nursing experience in an acute or outpatient setting
• At least 2 years of experience in utilization management within a managed care environment
• Familiarity with medical necessity criteria such as InterQual and CMS guidelines
• Experience with UM authorizations and appeals for DMEPOS is highly desirable