Remote UM Nurse (LPN/LVN) - Utilization & Appeals Expert

Integra Partners; Orangeburg (SC); À distance; USD 65 000 - 90 000; Plein temps

Avantages offerts par ce poste

Competitive compensation & annualbonus

401(k) with company match

Company-paid life insurance

Company-paid short term disability

Medical, Vision, and Dental benefits

Paid holidays and floating holidays

Health and wellness programs

Remote opportunities

Résumé du poste

Integra Partners is seeking an LPN/LVN with UM experience to perform pre-service and post-service utilization reviews and appeals for DMEPOS. You will collaborate with our Medical Director within an NCQA-compliant UM program to ensure medical necessity reviews meet federal and state requirements.

Responsibilities include reviewing against criteria, approving eligible requests, and referring non-qualifying cases to the Medical Director, while maintaining NCQA, CMS, and state accreditation

Qualifications

• Active LPN/LVN license in good standing.
• Minimum 3 years nursing in an acute or outpatient setting.
• Minimum 2 years UM experience in a managed care environment.
• Experience with Medical Necessity Criteria including InterQual, CMS guidelines, and health plan policies.

Responsabilités

• Perform pre-service and post-service UM authorization reviews utilizing mandates, plan language and NCDs/LCDs as 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.

Connaissances

LPN/LVN license

UM experience

Nursing

InterQual

Medical necessity

Formation

Description du poste

Integra Partners is seeking an LPN/LVN with UM experience to perform pre-service and post-service utilization reviews and appeals for DMEPOS. You will collaborate with our Medical Director within an NCQA-compliant UM program to ensure medical necessity reviews meet federal and state requirements.

Responsibilities include reviewing against criteria, approving eligible requests, and referring non-qualifying cases to the Medical Director, while maintaining NCQA, CMS, and state accreditation