Remote Utilization Management Nurse (LPN/LVN) - DMEPOS

Integra Partners; Massachusetts; Remote; USD 75,000 - 110,000; Full time

Benefits offered by this job

401(k) retirement program with company

Company-paid life insurance

Company-paid short term disability

Medical, Vision, and Dental benefits

Paid holidays and floating holidays

Health and wellness programs

Remote Opportunities

Job summary

Integra Partners is seeking an LPN/LVN with managed care UM experience to perform pre-service and post-service utilization reviews and appeals for DMEPOS. You will collaborate with our Medical Director to conduct benefit and medical necessity reviews within an NCQA-compliant UM program.

You will perform pre/post-service reviews, approve eligible requests, and escalate non-compliant cases. The role includes handling administrative and clinical appeals while maintaining accrediting standards and

Qualifications

• Active LPN/LVN license in good standing.
• Minimum 3 years of nursing in an acute or outpatient setting.
• Minimum 2 years UM experience in a managed care environment.
• Experience with medical necessity criteria (InterQual, CMS, plan policies).
• Experience writing denial letters preferred.

Responsibilities

• Perform pre-service and post-service UM reviews using federal/state mandates, plan benefits, 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.
• Maintain compliance with accrediting agency standards such as NCQA, CMS and State agencies.
• Collaborate with the Medical Director in review and appeals workflows.

Skills

LPN/LVN license

UM experience

Nursing in acute/outpatient

Medical necessity criteria knowledge

Education

Licensed Practical Nurse / Licensed Vocational Nurse license

Job description

Integra Partners is seeking an LPN/LVN with managed care UM experience to perform pre-service and post-service utilization reviews and appeals for DMEPOS. You will collaborate with our Medical Director to conduct benefit and medical necessity reviews within an NCQA-compliant UM program.

You will perform pre/post-service reviews, approve eligible requests, and escalate non-compliant cases. The role includes handling administrative and clinical appeals while maintaining accrediting standards and