Remote Utilization Management Nurse (LPN/LVN)

Integra Partners; Milton (MA); Remote; USD 75,000 - 100,000; Full time

Benefits offered by this job

Annual bonus program

401(k) with company match

Company-paid life insurance

Short term disability coverage

Medical, Vision, and Dental benefits

Remote opportunities

Job summary

Integra Partners seeks a licensed LVN/LPN with managed care UM experience to perform pre-service and post-service utilization reviews and appeals for DMEPOS, collaborating with the Medical Director within an NCQA-compliant UM program.

Responsibilities include evaluating requests against medical necessity, applying InterQual and CMS guidelines, approving eligible cases, and referring non-qualifying ones to the Medical Director.

Qualifications

• Active LVN/LPN license required.
• Minimum of 3 years nursing in acute or outpatient settings.
• Minimum of 2 years UM experience in managed care/payor environment.
• Experience with medical necessity criteria (InterQual, CMS, policies).
• Experience writing denial letters preferred.

Responsibilities

• Perform pre-service and post-service UM authorization reviews using mandates, plan language and criteria for medical necessity.
• Approve requests that meet eligibility, benefit and medical necessity criteria.
• Refer cases not meeting criteria to Medical Director.
• Process administrative and clinical appeals and refer as needed.
• Maintain compliance with NCQA, CMS and State standards.

Skills

UM experience

Medical necessity criteria

InterQual/CMS guidelines

Denial letter writing

Education

Licensed Vocational Nurse (LVN) license

Job description

Integra Partners seeks a licensed LVN/LPN with managed care UM experience to perform pre-service and post-service utilization reviews and appeals for DMEPOS, collaborating with the Medical Director within an NCQA-compliant UM program.

Responsibilities include evaluating requests against medical necessity, applying InterQual and CMS guidelines, approving eligible cases, and referring non-qualifying ones to the Medical Director.