Remote Utilization Management Nurse (LPN/LVN) – Appeals

Integra Partners; Colorado; Remote; USD 54,000 - 66,000; Full time

Benefits offered by this job

Annual bonus program

401(k) with company match

Company-paid life insurance

Company-paid short-term disability

Medical, Vision, and Dental benefits

PTO

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. The role collaborates with the Medical Director to assess benefit and medical necessity criteria and ensure compliance across DMEPOS.

The ideal candidate holds an active LPN/LVN license and has at least 3 years of nursing experience, with 2 years in UM within managed care. Colorado-based remote-friendly position with comprehensive benefits.

Qualifications

• Active LPN/LVN license required.
• Minimum 3 years of nursing in acute or outpatient settings.
• Minimum 2 years UM experience in managed care.
• Experience with Medicare/Medicaid is a plus.
• Familiarity with UM authorizations/appeals for DMEPOS desirable.
• Knowledge of medical necessity criteria including InterQual and CMS policies.

Responsibilities

• Perform pre-service and post-service UM reviews for medical necessity.
• Process UM authorizations and appeals with clinical criteria.
• Collaborate with Medical Director on benefit and medical necessity reviews.
• Communicate outcomes verbally and in writing; document thoroughly.
• Refer non-qualifying cases to Medical Director or IROs as needed.
• Maintain NCQA, CMS and state accreditation compliance.

Skills

UM review

Medical necessity criteria

Documentation writing

Verbal and written communication

Education

LPN/LVN license

Tools

InterQual

CMS guidelines

NCDs/LCDs

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. The role collaborates with the Medical Director to assess benefit and medical necessity criteria and ensure compliance across DMEPOS.

The ideal candidate holds an active LPN/LVN license and has at least 3 years of nursing experience, with 2 years in UM within managed care. Colorado-based remote-friendly position with comprehensive benefits.