Remote Utilization Management Nurse (LPN/LVN) – UM & Appeals
Integra Partners
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Benefits offered by this job
Job summary
Integra Partners is seeking an experienced LPN/LVN to perform pre-service and post-service utilization reviews and appeals within a NCQA-compliant UM program. You will collaborate with our Medical Director to assess benefits and medical necessity for DMEPOS under federal and state mandates.
The role involves reviewing requests, approving those meeting criteria, referring others to the Medical Director, and supporting accreditation efforts.
Qualifications
- Active LPN/LVN license in good standing.
- Minimum 3 years of nursing experience in acute or outpatient settings.
- At least 2 years of UM experience in managed care.
- Experience with InterQual, CMS guidelines, or health plan policies.
- Experience writing denial letters preferred.
Responsibilities
- Perform pre-service and post-service UM reviews using mandates and policies.
- Approve requests meeting eligibility and medical necessity criteria.
- Refer cases not meeting criteria to Medical Director.
- Process administrative and clinical appeals as needed.
- Maintain NCQA, CMS, and state accreditation compliance.
Skills
Education
Job description
Integra Partners is seeking an experienced LPN/LVN to perform pre-service and post-service utilization reviews and appeals within a NCQA-compliant UM program. You will collaborate with our Medical Director to assess benefits and medical necessity for DMEPOS under federal and state mandates.
The role involves reviewing requests, approving those meeting criteria, referring others to the Medical Director, and supporting accreditation efforts.
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