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

Integra Partners; Ohio; Remote; USD 65,000 - 90,000; Full time

Benefits offered by this job

Competitive compensation and annualbon

401(k) retirement program with company

Company-paid life insurance

Company-paid short term disability

Medical, Vision, and Dental benefits

Paid company holidays and floating HOA

Health and wellness programs

Remote Opportunities

Job summary

Integra Partners seeks an experienced LPN/LVN to conduct pre-service and post-service utilization reviews and appeals within a NCQA-compliant UM program, collaborating with our Medical Director.

The role emphasizes applying federal/state mandates, plan benefits, and guidelines such as InterQual and CMS to determine medical necessity, with responsibilities including approvals, referrals, and handling appeals. Remote opportunities available and strong team culture.

Qualifications

• Active LPN/LVN license required.
• Minimum 3 years of nursing in acute or outpatient settings.
• Minimum 2 years of utilization management experience in managed care.
• Experience with InterQual, CMS guidelines and health plan policies.
• Experience writing denial letters preferred.

Responsibilities

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

Skills

UM experience

InterQual knowledge

CMS guidelines

Medical policy familiarity

Denied letters experience

Education

LPN/LVN license

Job description

Integra Partners seeks an experienced LPN/LVN to conduct pre-service and post-service utilization reviews and appeals within a NCQA-compliant UM program, collaborating with our Medical Director.

The role emphasizes applying federal/state mandates, plan benefits, and guidelines such as InterQual and CMS to determine medical necessity, with responsibilities including approvals, referrals, and handling appeals. Remote opportunities available and strong team culture.