Remote Utilization Management Nurse (LPN/LVN) – Appeals

Integra Partners; East Windsor Hill (CT); Remote; USD 65,000 - 100,000; Full time

Benefits offered by this job

Competitive compensation and annual

bonus program

401(k) retirement program with company

company-paid life insurance

company-paid short term disability

Medical, Vision, and Dental benefits

Paid company holidays and floating

Health and wellness programs

Remote Opportunities

Job summary

Integra Partners is seeking an experienced LPN/LVN to perform pre-service and post-service utilization reviews and appeals for DMEPOS, in a NCQA-compliant UM program. The candidate will collaborate with our Medical Director on benefit and medical necessity reviews.

The role requires an active LPN/LVN license, at least 3 years of nursing experience in acute or outpatient settings, and at least 2 years in managed care utilization management.

Qualifications

• Active LPN/LVN license required.
• Minimum of 3 years nursing in acute or outpatient setting.
• Minimum of 2 years UM experience in a managed care payor environment.
• Experience with Medical Necessity Criteria (InterQual, CMS guidelines, health plan policies).
• Experience writing denial letters is preferred.

Responsibilities

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

Skills

UM experience

Nursing

Medical necessity criteria

Education

LPN/LVN license

Tools

InterQual

CMS guidelines

Job description

Integra Partners is seeking an experienced LPN/LVN to perform pre-service and post-service utilization reviews and appeals for DMEPOS, in a NCQA-compliant UM program. The candidate will collaborate with our Medical Director on benefit and medical necessity reviews.

The role requires an active LPN/LVN license, at least 3 years of nursing experience in acute or outpatient settings, and at least 2 years in managed care utilization management.