Remote Utilization Management Nurse (LPN/LVN) – Appeals & UM Expert

Integra Partners; Yuma (AZ); À distance; USD 65 000 - 90 000; Plein temps

Avantages offerts par ce poste

Bonus program

401(k) with match

Life insurance

Short-term disability

Medical, Vision, Dental

Résumé du poste

Integra Partners seeks a licensed practical nurse (LPN/LVN) with managed care experience to conduct pre-service and post-service utilization reviews and appeals for DMEPOS. You will collaborate with our Medical Director to review benefits and medical necessity within an NCQA-compliant UM program.

Responsibilities include authorizing reviews, routing non-qualifying cases to the Medical Director, and handling administrative and clinical appeals while ensuring compliance with accrediting bodies.

Qualifications

• UM experience in managed care payor environments.
• Ability to conduct pre-service and post-service utilization reviews.
• Familiarity with medical necessity criteria (InterQual, CMS, payer policies).
• Experience writing denial letters is a plus.
• Strong collaboration with Medical Director and compliance with NCQA standards.

Responsabilités

• Perform pre-service and post-service UM authorization reviews using mandates and plan benefits.
• Approve requests meeting eligibility and medical necessity criteria.
• Refer cases not meeting medical necessity to Medical Director.
• Process administrative and clinical appeals and route as needed.
• Maintain compliance with NCQA, CMS and state accrediting standards.

Connaissances

UM experience

Medical review work

InterQual/CMS criteria

Formation

LPN/LVN license

Description du poste

Integra Partners seeks a licensed practical nurse (LPN/LVN) with managed care experience to conduct pre-service and post-service utilization reviews and appeals for DMEPOS. You will collaborate with our Medical Director to review benefits and medical necessity within an NCQA-compliant UM program.

Responsibilities include authorizing reviews, routing non-qualifying cases to the Medical Director, and handling administrative and clinical appeals while ensuring compliance with accrediting bodies.