Remote UM Nurse (LPN/LVN) - Medical Necessity

Integra Partners; Texas; Remote; USD 60,000 - 90,000; Full time

Benefits offered by this job

Competitive compensation and annual BC

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

Health and wellness programs

Remote Opportunities

Job summary

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, collaborating with our Medical Director within an NCQA-compliant UM program.

The UM Nurse is responsible for reviews, approvals or referrals, handling appeals, and ensuring compliance with NCQA, CMS, and state standards. An active LVN/LPN license and 3+ years of nursing plus 2+ years UM in a payor environment are required.

Qualifications

• Active LVN/LPN 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, plan policies).
• Experience writing denial letters preferred.

Responsibilities

• Perform pre-service and post-service UM authorization reviews utilizing mandates, plan benefit language, and NCDs/LCDs as criteria.
• Approve requests that meet eligibility, benefit, and medical necessity criteria.
• Refer cases to the Medical Director that do not meet medical necessity criteria.
• 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.

Skills

UM experience

Nursing experience

Medical necessity criteria

Denial letters (preferred)

Tools

InterQual criteria

CMS guidelines

Job description

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, collaborating with our Medical Director within an NCQA-compliant UM program.

The UM Nurse is responsible for reviews, approvals or referrals, handling appeals, and ensuring compliance with NCQA, CMS, and state standards. An active LVN/LPN license and 3+ years of nursing plus 2+ years UM in a payor environment are required.