Remote Utilization Management Nurse (LPN/LVN)

Integra Partners; Lorida (FL); Remote; USD 70,000 - 90,000; Full time

Benefits offered by this job

401(k) match

Life insurance

Short term disability

Medical, Vision, and Dental

Paid holidays

Remote opportunities

Job summary

Integra Partners seeks an experienced LPN/LVN to perform pre-service and post-service utilization reviews and appeals within a NCQA-compliant UM program. You will collaborate with the Medical Director on benefit and medical necessity reviews, contributing to high-quality in-home care management across a national network.

The role requires active LPN/LVN licensure, 3+ years nursing in acute/outpatient settings, and 2+ years UM experience in managed care. Remote opportunities are available.

Qualifications

• Active LPN/LVN license required.
• Minimum 3 years nursing in acute or outpatient setting.
• Minimum 2 years UM experience in managed care/payor environment.
• Experience with Medical Necessity Criteria (InterQual, CMS, health plan policies).
• Experience writing denial letters preferred.

Responsibilities

• Perform pre-service and post-service UM authorization reviews per mandates and plan language.
• Approve requests meeting eligibility, benefit and medical necessity criteria.
• Refer cases to Medical Director when not meeting criteria.
• Process administrative and clinical appeals and escalate as needed.
• Maintain compliance with NCQA, CMS and state accrediting standards.

Skills

UM reviews

Medical necessity reviews

InterQual criteria

Education

LPN/LVN license

Tools

NCQA guidelines

CMS guidelines

Job description

Integra Partners seeks an experienced LPN/LVN to perform pre-service and post-service utilization reviews and appeals within a NCQA-compliant UM program. You will collaborate with the Medical Director on benefit and medical necessity reviews, contributing to high-quality in-home care management across a national network.

The role requires active LPN/LVN licensure, 3+ years nursing in acute/outpatient settings, and 2+ years UM experience in managed care. Remote opportunities are available.