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

Integra Partners; Kentucky; Remote; USD 65,000 - 95,000; Full time

Benefits offered by this job

401(k) retirement with company match

Life insurance

Short term disability

Medical, Vision, and Dental benefits

Paid holidays and floating holidays

Health and wellness programs

Remote opportunities

Job summary

Integra Partners seeks an experienced LPN/LVN to support utilization review in a managed care UM program. You will perform pre/post service reviews, determine medical necessity, and authorize eligible requests.

Collaborate with the Medical Director to refer non-compliant cases and manage administrative appeals within NCQA-aligned guidelines. Remote opportunities across the US are available.

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 (InterQual, CMS, health plan policies).
• Experience writing denial letters is preferred.

Responsibilities

• Perform pre-service and post-service UM authorization reviews using federal/state mandates and plan benefit language.
• Approve requests that meet eligibility, benefit, and medical necessity criteria.
• Refer cases to Medical Director when medical necessity criteria are not met.
• Process administrative and clinical appeals and refer as needed to Medical Director.
• Maintain compliance with NCQA, CMS and State accrediting standards.

Skills

Nursing experience

UM experience

Medical necessity criteria knowledge

Denial letters writing

Education

LPN/LVN license

Tools

InterQual

CMS guidelines

NCQA standards

Job description

Integra Partners seeks an experienced LPN/LVN to support utilization review in a managed care UM program. You will perform pre/post service reviews, determine medical necessity, and authorize eligible requests.

Collaborate with the Medical Director to refer non-compliant cases and manage administrative appeals within NCQA-aligned guidelines. Remote opportunities across the US are available.