Remote UM Nurse Care Manager (LPN/LVN)

Integra Partners; Texas; A distancia; USD 70.000 - 110.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Competitive compensation and annual BD

401(k) retirement program with company

Company-paid life insurance

Company-paid short term disability

Medical, Vision, and Dental benefits

Paid company holidays and floating HOL

Health and wellness programs

Remote Opportunities

Descripción de la vacante

Integra Partners is seeking an LPN/LVN with managed care UM experience to perform pre-service and post-service utilization reviews and appeals for DMEPOS in a NCQA-compliant UM program.

The UM Nurse will collaborate with the Medical Director to review benefit and medical necessity criteria, authorize eligible requests, and refer non-qualifying cases for director review. This role offers remote opportunities and a comprehensive benefits package.

Formación

• Active LPN/LVN license in good standing.
• Minimum 3 years of nursing in an acute or outpatient setting.
• Minimum 2 years of UM experience in a managed care, payor environment.
• Experience with Medical Necessity Criteria (InterQual, CMS guidelines, health plan policies).
• Experience writing denial letters preferred.

Responsabilidades

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

Conocimientos

LPN/LVN license

UM experience

Medical necessity criteria

Nursing in acute/outpatient

Denial letters experience

Descripción del empleo

Integra Partners is seeking an LPN/LVN with managed care UM experience to perform pre-service and post-service utilization reviews and appeals for DMEPOS in a NCQA-compliant UM program.

The UM Nurse will collaborate with the Medical Director to review benefit and medical necessity criteria, authorize eligible requests, and refer non-qualifying cases for director review. This role offers remote opportunities and a comprehensive benefits package.