Remote Utilization Management Nurse (LPN/LVN)

Integra Partners; Alton (IL); Remote; USD 60,000 - 85,000; 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 hol

Health and wellness programs

Remote Opportunities

Job summary

Integra Partners seeks an experienced LPN/LVN to perform pre-service and post-service UM reviews and appeals within a NCQA-compliant UM program. You will collaborate with the Medical Director on benefit and medical necessity reviews in a managed care setting.

The role requires active nursing licensure, 3+ years in acute/outpatient care, and 2+ years in UM within a payor environment, with familiarity with InterQual and CMS guidelines. Remote opportunities are available.

Qualifications

• Active LPN/LVN license preferred with prior UM exposure.
• Experience performing pre/post service reviews for medical necessity.
• Familiarity with InterQual, CMS guidelines and health plan policies.
• Ability to author clear denial letters when appropriate.

Responsibilities

• Perform pre-service and post-service UM reviews using mandates and plan language.
• Approve requests meeting eligibility and medical necessity criteria.
• Refer non-eligible cases to Medical Director for review.
• Process administrative and clinical appeals as needed.
• Maintain NCQA, CMS and state accreditation compliance.

Skills

LPN/LVN license

3+ years nursing

2+ years UM experience

Acute care nursing

Medical necessity criteria

Education

Nursing diploma/ADN

Tools

InterQual

CMS guidelines

NCQA standards

Job description

Integra Partners seeks an experienced LPN/LVN to perform pre-service and post-service UM reviews and appeals within a NCQA-compliant UM program. You will collaborate with the Medical Director on benefit and medical necessity reviews in a managed care setting.

The role requires active nursing licensure, 3+ years in acute/outpatient care, and 2+ years in UM within a payor environment, with familiarity with InterQual and CMS guidelines. Remote opportunities are available.