Remote Utilization Management Nurse (LPN/LVN) – Appeals

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

Benefits offered by this job

Competitive compensation and annualBON

401(k) retirement program with company

Company-paid life insurance

Short term disability coverage

Medical, Vision, and Dental benefits

Paid Time Off (PTO)

Paid Parental Leave

Sick Time

Holidays and floating holidays

Wellness programs

Career development opportunities

Job summary

Integra Partners is seeking an LPN/LVN experienced in the managed care UM environment to perform pre-service and post-service utilization reviews for DMEPOS, in collaboration with our Medical Director.

The role supports benefit and medical necessity reviews and appeals within a NCQA-compliant UM program, ensuring accurate determinations and timely communication with providers and members.

Qualifications

• Active LPN/LVN license required.
• Minimum of 3 years of nursing in an acute or outpatient setting.
• Minimum of 2 years of UM experience in a managed care/payor environment.
• Experience with Medicare/Medicaid desirable.
• Experience with UM authorizations and appeals for DMEPOS desirable.
• Experience with Medical Necessity Criteria including InterQual, CMS guidelines, health plan policies.
• Strong verbal and written communication skills.

Responsibilities

• Perform pre-service and post-service UM authorization reviews using federal/state mandates and plan criteria.
• Collaborate with non-clinical teams to obtain necessary information.
• Approve requests that meet eligibility, benefit, and medical necessity criteria.
• Refer cases not meeting criteria to the Medical Director or to IROs as needed.
• Communicate UM outcomes verbally and in writing.
• Process administrative and clinical appeals as needed.

Skills

UM experience

Nursing license

Communication skills

Education

LPN/LVN license

Tools

InterQual

CMS guidelines

Job description

Integra Partners is seeking an LPN/LVN experienced in the managed care UM environment to perform pre-service and post-service utilization reviews for DMEPOS, in collaboration with our Medical Director.

The role supports benefit and medical necessity reviews and appeals within a NCQA-compliant UM program, ensuring accurate determinations and timely communication with providers and members.