Remote UM Nurse LPN - Utilization Review & Appeals (DMEPOS)

Integra Partners; New York (NY); Remote; USD 55,000 - 85,000; Full time

Benefits offered by this job

401(k) 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 is seeking an experienced LPN/LVN to perform pre-service and post-service utilization reviews and appeals in a managed care UM program. You will collaborate with our Medical Director on benefit and medical necessity reviews for DMEPOS.

The role requires active nursing licensure, 2+ years UM experience in payor environments, and familiarity with InterQual and CMS guidelines. Remote opportunities are available along with a comprehensive benefits package.

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/payor environment.
• Experience with Medical Necessity Criteria including InterQual, CMS guidelines, and health plan policies.

Responsibilities

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

Skills

LPN/LVN license

UM experience in managed care

Medical necessity criteria

DMEPOS/UM documentation

Job description

Integra Partners is seeking an experienced LPN/LVN to perform pre-service and post-service utilization reviews and appeals in a managed care UM program. You will collaborate with our Medical Director on benefit and medical necessity reviews for DMEPOS.

The role requires active nursing licensure, 2+ years UM experience in payor environments, and familiarity with InterQual and CMS guidelines. Remote opportunities are available along with a comprehensive benefits package.