Remote UM Nurse LPN — Utilization Review & Appeals

Integra Partners; Lorida (FL); Remote; USD 75,000 - 90,000; Full time

Benefits offered by this job

Competitive compensation

401(k) with company match

Company-paid life insurance

Short term disability

Medical, Vision, and Dental

Paid holidays

Health and wellness programs

Remote opportunities

Job summary

Integra Partners seeks an experienced LPN/LVN to perform pre-service and post-service utilization reviews and appeals for DMEPOS in a managed care environment. You will collaborate with the Medical Director to ensure medical necessity reviews align with NCQA-compliant UM program standards.

The role requires active LPN/LVN licensure, at least 3 years of nursing in acute or outpatient care, and 2+ years UM experience.

Qualifications

• Active LPN/LVN license.
• Minimum 3 years of nursing in acute or outpatient setting.
• Minimum 2 years of UM experience in managed care/payor environment.
• Experience with Medical Necessity Criteria (InterQual, CMS, etc.).
• Experience writing denial letters 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 not meeting medical necessity criteria.
• Process administrative and clinical appeals and refer as needed to Medical Director.
• Maintain compliance with NCQA, CMS, and State accrediting standards.

Skills

LPN/LVN license

UM experience

Nursing in acute/outpatient

Medical necessity reviews

Tools

InterQual

CMS guidelines

Job description

Integra Partners seeks an experienced LPN/LVN to perform pre-service and post-service utilization reviews and appeals for DMEPOS in a managed care environment. You will collaborate with the Medical Director to ensure medical necessity reviews align with NCQA-compliant UM program standards.

The role requires active LPN/LVN licensure, at least 3 years of nursing in acute or outpatient care, and 2+ years UM experience.