Remote LPN UM Nurse: Care Management & Appeals

Integra Partners; Columbia (SC); Remote; USD 55,000 - 75,000; Full time

Benefits offered by this job

Remote opportunities

401(k) retirement with company match

Company-paid life insurance

Company-paid short-term disability

Medical, Vision, and Dental benefits

Paid holidays and floating holidays

Health and wellness programs

Job summary

Integra Partners is seeking an experienced LPN/LVN to conduct pre-service and post-service utilization reviews and appeals for DMEPOS within a NCQA-compliant UM program. The role collaborates with the Medical Director on benefit and medical necessity reviews.

The UM Nurse will perform reviews, approve eligible requests, refer non-qualifying cases, and handle appeals while ensuring compliance with NCQA, CMS, and state standards. Remote opportunities are available across the United States.

Qualifications

• Minimum of 2 years of UM experience in a managed care payor environment.
• Experience with Medical Necessity Criteria including InterQual, CMS guidelines, and health plan policies.
• Experience writing denial letters is preferred.

Responsibilities

• Perform pre-service and post-service UM authorization reviews utilizing federal/state mandates, plan benefits, and NCDs/LCDs as criteria for medical necessity reviews.
• Approve requests that meet eligibility, benefit, and medical necessity criteria.
• Refer cases to the Medical Director when medical necessity criteria are not met.
• Process administrative and clinical appeals and refer as needed to the Medical Director.
• Maintain compliance with NCQA, CMS and State agency standards.

Skills

UM experience in managed care

Medical necessity knowledge

InterQual/CMS guidelines familiarity

Education

LPN/LVN license

Job description

Integra Partners is seeking an experienced LPN/LVN to conduct pre-service and post-service utilization reviews and appeals for DMEPOS within a NCQA-compliant UM program. The role collaborates with the Medical Director on benefit and medical necessity reviews.

The UM Nurse will perform reviews, approve eligible requests, refer non-qualifying cases, and handle appeals while ensuring compliance with NCQA, CMS, and state standards. Remote opportunities are available across the United States.