Remote Utilization Management Nurse (LPN/LVN)

Integra Partners; South Carolina; Remote; USD 70,000 - 90,000; Full time

Benefits offered by this job

Competitive pay

Annual bonus program

401(k) with company match

Company-paid life insurance

Short-term disability

Medical, Vision, Dental

Paid holidays

Wellness programs

Remote opportunities

Job summary

Integra Partners is seeking a licensed practical/vocational nurse to perform pre-service and post-service utilization management reviews, applying federal/state mandates and plan language to determine medical necessity. The role includes approving eligible requests and referring non-qualifying cases to the Medical Director, with processing appeals as needed.

The position supports compliance with NCQA, CMS and state standards, and offers remote opportunities along with competitive compensation

Qualifications

• Active, LVN or LPN license must be current.
• 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 policies, etc.).
• Experience writing denial letters preferred.

Responsibilities

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

Skills

Nursing license (LVN/LPN)

UM review experience

Medical necessity criteria

DMEPOS or payor environment

Denied letters experience

Job description

Integra Partners is seeking a licensed practical/vocational nurse to perform pre-service and post-service utilization management reviews, applying federal/state mandates and plan language to determine medical necessity. The role includes approving eligible requests and referring non-qualifying cases to the Medical Director, with processing appeals as needed.

The position supports compliance with NCQA, CMS and state standards, and offers remote opportunities along with competitive compensation