Remote Utilization Management Nurse (LPN/LVN)

Integra Partners; Williamstown (NJ); Remote; USD 65,000 - 90,000; Full time

Benefits offered by this job

Remote opportunities

401(k) with company match

Life insurance

Health, vision, dental

Job summary

Integra Partners seeks an experienced LPN/LVN to conduct utilization reviews for DMEPOS within an NCQA-compliant UM program. You will collaborate with the Medical Director on benefit determinations and medical necessity reviews, performing pre- and post-service UM activities.

The ideal candidate has 3+ years nursing experience, 2+ years in UM within managed care, and familiarity with InterQual/CMS guidelines to support timely authorizations and appeals.

Qualifications

• Active, Licensed Vocational Nurse or Licensed Practical Nurse license is required.
• Minimum 3 years of nursing in an acute or outpatient setting.
• Minimum 2 years of UM experience in a managed care, payor environment.
• Experience with Medical Necessity Criteria such as InterQual, CMS guidelines, health plan policies.

Responsibilities

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

Skills

UM in managed care

Nursing (3 years)

Medical necessity reviews

Appeals writing

InterQual/CMS guidelines

Education

LPN/LVN license

Tools

InterQual

CMS guidelines

Job description

Integra Partners seeks an experienced LPN/LVN to conduct utilization reviews for DMEPOS within an NCQA-compliant UM program. You will collaborate with the Medical Director on benefit determinations and medical necessity reviews, performing pre- and post-service UM activities.

The ideal candidate has 3+ years nursing experience, 2+ years in UM within managed care, and familiarity with InterQual/CMS guidelines to support timely authorizations and appeals.