Remote Utilization Management Nurse (LPN/LVN)

Integra Partners; Clifton (TX); Remote; USD 60,000 - 90,000; Full time

Benefits offered by this job

Competitive compensation + annualBonus

401(k) with company match

Company-paid life insurance

Short-term disability coverage

Health, Vision, Dental benefits

Paid holidays + floating holidays

Wellness programs

Remote opportunities

Job summary

Integra Partners seeks an experienced LPN/LVN to perform pre-service and post-service utilization reviews and appeals within an NCQA-compliant UM program. You will collaborate with our Medical Director on benefit and medical necessity reviews and drive quality outcomes.

Ideal candidate has 3+ years of nursing in acute/outpatient settings and 2+ years in managed care UM, with familiarity of InterQual and CMS guidelines. Remote opportunities available within the United States.

Qualifications

• Active, licensed LVN/LPN with current licensure.
• 3+ years nursing in acute or outpatient settings.
• 2+ years in utilization management within a managed care payor environment.
• Experience with medical necessity criteria and denial letters preferred.

Responsibilities

• Perform pre-service and post-service UM reviews using mandates, plan benefits, and NCDs/LCDs as criteria for medical necessity.
• Approve requests meeting eligibility and medical necessity; refer others to Medical Director.
• Process administrative and clinical appeals as needed.
• Maintain compliance with NCQA, CMS, and state standards.

Skills

LPN/LVN license

UM/managed care experience

Nursing in acute/outpatient

Med policy knowledge (InterQual/CMS)

Education

LPN/LVN license (state-verified)

Tools

InterQual knowledge

CMS guidelines familiarity

Job description

Integra Partners seeks an experienced LPN/LVN to perform pre-service and post-service utilization reviews and appeals within an NCQA-compliant UM program. You will collaborate with our Medical Director on benefit and medical necessity reviews and drive quality outcomes.

Ideal candidate has 3+ years of nursing in acute/outpatient settings and 2+ years in managed care UM, with familiarity of InterQual and CMS guidelines. Remote opportunities available within the United States.