Remote UM Nurse: Utilization Review & Appeals (LPN/LVN)

Integra Partners; Florida; À distance; USD 60 000 - 90 000; Plein temps

Avantages offerts par ce poste

Competitive compensation & annualbonus

401(k) with company match

Company-paid life insurance

Short term disability coverage

Medical, Vision, and Dental

Holidays & floating holidays

Health & wellness programs

Remote opportunities

Résumé du poste

Integra is looking for a LPN/LVN experienced in the managed care payor environment to perform pre-service and post-service utilization reviews and appeals for DMEPOS. This role collaborates with our Medical Director to perform benefit and medical necessity reviews within an NCQA-compliant UM program.

The UM Nurse’s responsibilities include pre-service/post-service reviews, approvals, referrals to Medical Director, and handling appeals while ensuring compliance with NCQA, CMS and state standards.

Qualifications

• Active, Licensed Vocational Nurse or Licensed Practical Nurse 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 but not limited to InterQual, CMS guidelines, health plan medical policies, etc.

Responsabilités

• Perform pre-service and post-service UM authorization reviews utilizing federal and state mandates, plan benefit language and NCDs/LCDs as criteria for medical necessity reviews.
• 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 accrediting agency standards such as NCQA, CMS and State agencies.

Connaissances

LPN/LVN license

UM experience

Medical necessity knowledge

Denied letters writing

Formation

LPN/LVN license (RN not specified)

Outils

InterQual guidelines

CMS guidelines

Description du poste

Integra is looking for a LPN/LVN experienced in the managed care payor environment to perform pre-service and post-service utilization reviews and appeals for DMEPOS. This role collaborates with our Medical Director to perform benefit and medical necessity reviews within an NCQA-compliant UM program.

The UM Nurse’s responsibilities include pre-service/post-service reviews, approvals, referrals to Medical Director, and handling appeals while ensuring compliance with NCQA, CMS and state standards.