Remote UM Nurse LPN - Utilization Reviews & Appeals

Integra Partners; Clifton (TX); À distance; USD 65 000 - 90 000; Plein temps

Avantages offerts par ce poste

Competitive compensation and annualBON

401(k) with company match

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 experienced LPN/LVN to perform pre-service and post-service utilization reviews and appeals in a managed care UM program. This role collaborates with the Medical Director on benefit and medical necessity reviews, aligned with NCQA standards.

The UM Nurse will review requests, approve those meeting criteria, and refer others to leadership. This position requires nursing experience and familiarity with InterQual, CMS guidelines, and payer policies.

Qualifications

• Active LPN/LVN license
• Minimum 3 years of nursing in an acute or outpatient setting
• Minimum 2 years of UM experience in a managed care environment
• Experience with medical necessity criteria (InterQual, CMS, health plan policies)
• Experience in writing denial letters preferred

Responsabilités

• Perform pre-service and post-service UM authorization reviews using mandates, plan language and NCDs/LCDs for medical necessity reviews
• 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 refer as needed to Medical Director
• Maintain compliance with NCQA, CMS and state agency standards

Connaissances

UM experience

Medical terminology

Documentation

Communication

Formation

LPN/LVN license

Outils

InterQual

CMS guidelines

Health plan policies

Description du poste

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. This role collaborates with the Medical Director on benefit and medical necessity reviews, aligned with NCQA standards.

The UM Nurse will review requests, approve those meeting criteria, and refer others to leadership. This position requires nursing experience and familiarity with InterQual, CMS guidelines, and payer policies.