Remote UM Nurse LPN – Utilization Review & Appeals

Integra Partners; Georgia; À distance; USD 45 000 - 65 000; Plein temps

Avantages offerts par ce poste

Competitive compensation

401(k) retirement program with company

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 managed care experience to perform pre-service and post-service utilization reviews and appeals for DMEPOS.

You will collaborate with our Medical Director to ensure benefit and medical necessity reviews meet NCQA UM standards, using InterQual and CMS guidelines.

The role supports a nationwide remote workforce with competitive compensation, benefits, and a bonus program.

Qualifications

• Active, Licensed Vocational Nurse (LPN) or Licensed Practical Nurse (LVN) license.
• Minimum of 3 years of nursing in an acute or outpatient setting.
• Minimum of 2 years of UM experience in a managed care payor environment.
• Experience with Medical Necessity Criteria including InterQual, CMS guidelines, and health plan medical policies.
• Experience writing denial letters is preferred.

Responsabilités

• Perform pre-service and post-service UM authorization 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 Medical Director that do not meet medical necessity criteria and initiate appeals as needed.
• Process administrative and clinical appeals and refer as needed to the Medical Director.
• Maintain compliance with accrediting standards such as NCQA, CMS and State agencies.

Connaissances

LPN/LVN license

UM in managed care

NCQA UM program knowledge

Medical necessity criteria

Formation

LPN/LVN license

Description du poste

Integra Partners is seeking an LPN/LVN with managed care experience to perform pre-service and post-service utilization reviews and appeals for DMEPOS.

You will collaborate with our Medical Director to ensure benefit and medical necessity reviews meet NCQA UM standards, using InterQual and CMS guidelines.

The role supports a nationwide remote workforce with competitive compensation, benefits, and a bonus program.