Remote UM Nurse (LPN/LVN) – Utilization & Appeals

Integra Partners; Georgia; Remote; USD 55,000 - 72,000; Full time

Benefits offered by this job

Competitive compensation and annual/bd

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

Remote opportunities

Job summary

Integra Partners seeks a licensed LPN/LVN with managed care UM experience to perform pre-service and post-service utilization reviews and appeals. You will collaborate with our Medical Director to review benefit and medical necessity and support NCQA-compliant UM processes within our program.

The role requires active nursing licensure, 3+ years of nursing, and 2+ years in UM. Remote opportunities are available across the United States, with a focus on accuracy and efficient decision-making.

Qualifications

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

Responsibilities

• Perform pre-service and post-service UM reviews utilizing federal and state mandates, plan benefit language and criteria for medical necessity reviews.
• 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 agency standards such as NCQA, CMS and State agencies.

Skills

UM experience in managed care

Nursing experience

Medical necessity criteria knowledge

Denial letters (preferred)

Job description

Integra Partners seeks a licensed LPN/LVN with managed care UM experience to perform pre-service and post-service utilization reviews and appeals. You will collaborate with our Medical Director to review benefit and medical necessity and support NCQA-compliant UM processes within our program.

The role requires active nursing licensure, 3+ years of nursing, and 2+ years in UM. Remote opportunities are available across the United States, with a focus on accuracy and efficient decision-making.