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

Integra Partners; Atlanta (GA); Remote; USD 62,000 - 78,000; Full time

Benefits offered by this job

Annual bonus

401(k) with company match

Company-paid life insurance

Short-term disability

Medical, vision, dental benefits

Paid holidays

Remote opportunities

Wellness programs

Job summary

Integra Partners is seeking an experienced LPN/LVN to perform pre-service and post-service utilization reviews and appeals for DMEPOS within a NCQA-compliant UM program. You will collaborate with the Medical Director to assess medical necessity and benefit coverage.

The candidate must hold an active LPN/LVN license, with at least 3 years of nursing experience and 2 years in managed care UM, and have knowledge of InterQual and CMS criteria.

Qualifications

• Active LPN/LVN license in good standing.
• Minimum 3 years nursing in acute or outpatient setting.
• Minimum 2 years UM experience in managed care.
• Experience with Medical Necessity Criteria including InterQual and CMS.
• Experience writing denial letters preferred.

Responsibilities

• Perform pre-service and post-service UM reviews to assess medical necessity.
• Approve requests that meet eligibility, benefit, and medical necessity criteria.
• Refer cases to the Medical Director when criteria are not met.
• Process administrative and clinical appeals as needed.
• Maintain NCQA, CMS, and state accreditation compliance.

Skills

LPN/LVN license

UM experience

Medical necessity

InterQual criteria

CMS guidelines

Job description

Integra Partners is seeking an experienced LPN/LVN to perform pre-service and post-service utilization reviews and appeals for DMEPOS within a NCQA-compliant UM program. You will collaborate with the Medical Director to assess medical necessity and benefit coverage.

The candidate must hold an active LPN/LVN license, with at least 3 years of nursing experience and 2 years in managed care UM, and have knowledge of InterQual and CMS criteria.