Remote UM Nurse (LPN) – Utilization Review & Appeals

Integra Partners; Springfield (IL); Remote; USD 60,000 - 85,000; Full time

Benefits offered by this job

401(k) with company match

Company-paid life insurance

Company-paid short term disability

Health, Vision, and Dental benefits

Paid holidays & floating holidays

Remote opportunities

Job summary

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

Responsibilities include evaluating requests, approving those meeting criteria, and referring non-meeting cases. Remote opportunities available; competitive compensation and benefits provided.

Qualifications

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

Responsibilities

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

Skills

LPN/LVN license

UM in managed care

Nursing in acute/outpatient

Medical necessity criteria (InterQual,

Denied letters writing

Job description

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

Responsibilities include evaluating requests, approving those meeting criteria, and referring non-meeting cases. Remote opportunities available; competitive compensation and benefits provided.