Remote Utilization Management Nurse (LPN/LVN) – Appeals

Integra Partners; Eagle (ID); Remote; USD 60,000 - 90,000; Full time

Benefits offered by this job

Competitive compensation

Annual bonus program

401(k) with company match

Life insurance

Short term disability

Medical, Vision, and Dental benefits

Paid holidays and floating holidays

Health and wellness programs

Remote opportunities

Job summary

Integra Partners seeks an experienced LPN/LVN with strong UM background to perform pre-service and post-service utilization reviews and appeals for DMEPOS. You will collaborate with the Medical Director on benefit and medical necessity reviews within an NCQA-compliant UM program.

Responsibilities include authorizing eligible requests, routing non-eligible cases to the Medical Director, and handling appeals while maintaining compliance with NCQA, CMS and state standards.

Qualifications

• Active LPN/LVN license in good standing.
• Minimum 3 years nursing in acute or outpatient settings.
• Minimum 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 to Medical Director when criteria are not met.
• Process administrative and clinical appeals and escalate as needed.
• Maintain compliance with NCQA, CMS, and state accrediting standards.

Skills

UM experience

Medical necessity criteria

Denial letters (experience)

LPN/LVN license

Team collaboration

Education

LPN/LVN license

Tools

InterQual

CMS guidelines

Job description

Integra Partners seeks an experienced LPN/LVN with strong UM background to perform pre-service and post-service utilization reviews and appeals for DMEPOS. You will collaborate with the Medical Director on benefit and medical necessity reviews within an NCQA-compliant UM program.

Responsibilities include authorizing eligible requests, routing non-eligible cases to the Medical Director, and handling appeals while maintaining compliance with NCQA, CMS and state standards.