Remote UM Nurse LPN - Utilization Review & Appeals

Integra Partners; Alton (IL); Remote; USD 60,000 - 90,000; Full time

Benefits offered by this job

Competitive compensation plus annual

401(k) with company match

Company-paid life insurance

Company-paid short-term disability

Medical, Vision, Dental benefits

Paid holidays and floating holidays

Health and wellness programs

Remote opportunities

Job summary

Integra Partners is seeking an experienced LPN/LVN to conduct pre-service and post-service utilization reviews and appeals in a managed care environment. You will collaborate with our Medical Director to evaluate medical necessity and benefit coverage within an NCQA-compliant UM program.

The role requires active licensure, 3+ years of nursing experience, and 2+ years UM experience. Knowledge of InterQual and CMS guidelines is preferred, and we offer remote work options and a comprehensive

Qualifications

• Active LVN/LPN license required.
• Minimum of 3 years nursing experience in acute or outpatient settings.
• Minimum of 2 years UM experience in managed care/payor environment.
• Experience with medical necessity criteria (InterQual, CMS, health plan policies) preferred.

Responsibilities

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

Skills

LPN/LVN license

Nursing experience

UM experience

InterQual knowledge

Job description

Integra Partners is seeking an experienced LPN/LVN to conduct pre-service and post-service utilization reviews and appeals in a managed care environment. You will collaborate with our Medical Director to evaluate medical necessity and benefit coverage within an NCQA-compliant UM program.

The role requires active licensure, 3+ years of nursing experience, and 2+ years UM experience. Knowledge of InterQual and CMS guidelines is preferred, and we offer remote work options and a comprehensive