Remote UM Nurse - LPN/LVN Care Management & Appeals

Integra Partners; Williamstown (NJ); Remote; USD 65,000 - 90,000; Full time

Benefits offered by this job

401(k) retirement program with company

Company-paid life insurance

Company-paid short term disability

Medical, Vision, and Dental benefits

Paid company holidays

Remote Opportunities

Job summary

Integra Partners is seeking 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 the Medical Director to assess medical necessity and benefit coverage.

The ideal candidate has 2+ years UM experience in managed care, 3+ years of nursing in acute or outpatient settings, and strong knowledge of InterQual/CMS policies.

Qualifications

• Active, Licensed Vocational Nurse (LPN) or Licensed Practical Nurse license.
• Minimum of 3 years of nursing in an acute or outpatient setting.
• Minimum of 2 years of UM experience in a managed care, payor environment.
• Experience with Medical Necessity Criteria including InterQual, CMS guidelines, health plan medical policies.

Responsibilities

• Perform pre-service and post-service UM authorization reviews utilizing mandates and plan language.
• Approve requests meeting eligibility, benefit, and medical necessity criteria.
• Refer cases to Medical Director when not meeting medical necessity criteria.
• Process administrative and clinical appeals and refer as needed to Medical Director.
• Maintain compliance with NCQA, CMS and State agencies.

Skills

LPN/LVN license

UM experience in managed care

Nursing in acute/outpatient

Medical necessity criteria (InterQual,

Ability to write denial letters

Job description

Integra Partners is seeking 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 the Medical Director to assess medical necessity and benefit coverage.

The ideal candidate has 2+ years UM experience in managed care, 3+ years of nursing in acute or outpatient settings, and strong knowledge of InterQual/CMS policies.