Remote UM Nurse LPN – Care Management & Appeals

Integra Partners; Phoenix (AZ); Remote; USD 60,000 - 80,000; Full time

Benefits offered by this job

401(k) retirement plan with company/ 1

Company-paid life insurance

Company-paid short term disability

Job summary

Integra Partners seeks an LPN/LVN with managed care UM experience to perform pre-service and post-service utilization reviews for DMEPOS. You will collaborate with the Medical Director on benefit and medical necessity decisions within a NCQA-compliant UM program.

The role involves applying federal and state mandates, plan benefit language, and criteria such as InterQual and CMS guidelines to authorize or deny requests, while handling appeals and maintaining strict compliance with accrediting

Qualifications

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

Responsibilities

• Perform pre-service and post-service UM reviews using plan benefit language and approved criteria.
• Approve requests that meet eligibility, benefit, and medical necessity criteria; refer non-eligible cases to Medical Director.
• Process administrative and clinical appeals; refer as needed to the Medical Director.
• Maintain compliance with NCQA, CMS and state accrediting standards.

Skills

UM experience

Medical necessity criteria

CMS/NCDs/LCDs knowledge

Documentation/denial letters

InterQual

Communication skills

Education

LPN/LVN license

Tools

Electronic Health Records

CMS guidelines

Job description

Integra Partners seeks an LPN/LVN with managed care UM experience to perform pre-service and post-service utilization reviews for DMEPOS. You will collaborate with the Medical Director on benefit and medical necessity decisions within a NCQA-compliant UM program.

The role involves applying federal and state mandates, plan benefit language, and criteria such as InterQual and CMS guidelines to authorize or deny requests, while handling appeals and maintaining strict compliance with accrediting