Remote Utilization Management Nurse (LPN/LVN)

Integra Partners; Clayton (NC); On-site; USD 54,000 - 66,000; Full time

Benefits offered by this job

Annual bonus

401(k) match

Life insurance

Short-term disability

Medical benefits

PTO

Parental leave

Sick time

Holidays

Wellness programs

Career development

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 for DMEPOS. You will collaborate with the Medical Director on benefit and medical necessity determinations.

The role requires strong knowledge of Medicare/Medicaid concepts, UM authorizations, and effective communication, with opportunities to impact patient care and payer relations.

Qualifications

• Perform pre-service and post-service UM authorization reviews using federal/state mandates, plan benefit language and criteria.
• Coordinate with non-clinical team to obtain needed clinical information.
• Approve requests meeting eligibility, benefit and medical necessity criteria.

Responsibilities

• Communicate outcomes of UM reviews verbally and in writing.
• Process administrative and clinical appeals and refer to Medical Director as needed.
• Maintain compliance with NCQA, CMS and state accrediting standards.
• Perform other duties as assigned.

Skills

UM pre-/post-service reviews

Medical necessity criteria

NCQA CMS compliance

Communicate outcomes (oral/written)

Case processing of appeals

Collaboration with Medical Director

Documentation and letters

Education

Active 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 for DMEPOS. You will collaborate with the Medical Director on benefit and medical necessity determinations.

The role requires strong knowledge of Medicare/Medicaid concepts, UM authorizations, and effective communication, with opportunities to impact patient care and payer relations.