Remote UM Nurse LPN — Care Management & Appeals

Integra Partners; East Windsor Hill (CT); Remote; USD 70.000 - 95.000; Vollzeit

Benefits dieser Stelle

Bonus program

401(k) with match

Life insurance

Disability coverage

Medical/Vision/Dental

Paid holidays

Wellness programs

Remote opportunities

Zusammenfassung

Integra Partners is seeking an experienced LPN/LVN to perform pre-service and post-service utilization reviews and appeals within a NCQA-compliant UM program. You will collaborate with our Medical Director on benefit and medical necessity reviews in a managed care/payor environment.

The role requires active nursing licensure, 3+ years in acute/outpatient settings, and 2+ years in UM. Strong knowledge of medical necessity criteria (InterQual/CMS) is essential; denial-letter experience is a plus.

Qualifikationen

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

Aufgaben

• Perform pre-service and post-service UM reviews using mandates and plan language.
• Approve requests meeting eligibility, benefit, and medical necessity criteria.
• Refer cases not meeting medical necessity to Medical Director.
• Process administrative and clinical appeals and escalate as needed.
• Maintain compliance with NCQA, CMS, and state standards.

Kenntnisse

UM experience

Medical necessity reviews

Acute/outpatient nursing

Ausbildung

LPN/LVN license

Tools

InterQual

CMS guidelines

Jobbeschreibung

Integra Partners is seeking an experienced LPN/LVN to perform pre-service and post-service utilization reviews and appeals within a NCQA-compliant UM program. You will collaborate with our Medical Director on benefit and medical necessity reviews in a managed care/payor environment.

The role requires active nursing licensure, 3+ years in acute/outpatient settings, and 2+ years in UM. Strong knowledge of medical necessity criteria (InterQual/CMS) is essential; denial-letter experience is a plus.