Remote UM Nurse LPN: Care Management & Appeals

Integra Partners; Massachusetts; Remote; USD 75,000 - 110,000; Full time

Benefits offered by this job

401(k) match

Life insurance

Remote opportunities

Medical, Vision, and Dental

Job summary

Integra Partners seeks an experienced LPN/LVN to conduct pre-service and post-service utilization reviews and appeals for DMEPOS within an NCQA-compliant UM program. You will collaborate with our Medical Director on benefit and medical necessity decisions.

The role requires an active LPN/LVN license, at least 3 years nursing in acute or outpatient settings, and 2+ years UM experience in managed care. Remote opportunities are available and you will help ensure high-quality, compliant care.

Qualifications

• Active LPN/LVN license
• Minimum of 3 years nursing experience in acute or outpatient settings
• Minimum of 2 years UM experience in a managed care environment
• Experience with InterQual, CMS guidelines, health plan medical policies, etc.
• Experience writing denial letters preferred

Responsibilities

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

Skills

Collaboration

Attention to detail

Education

LPN/LVN Licensure

Job description

Integra Partners seeks an experienced LPN/LVN to conduct pre-service and post-service utilization reviews and appeals for DMEPOS within an NCQA-compliant UM program. You will collaborate with our Medical Director on benefit and medical necessity decisions.

The role requires an active LPN/LVN license, at least 3 years nursing in acute or outpatient settings, and 2+ years UM experience in managed care. Remote opportunities are available and you will help ensure high-quality, compliant care.