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

Integra Partners; Central City (KY); Remote; USD 70,000 - 90,000; Full time

Benefits offered by this job

Competitive compensation and annualBON

401(k) with company match

Company-paid life insurance

Company-paid short term disability

Health, Vision, and Dental benefits

Paid company holidays and floating9hol

Job summary

Integra Partners is seeking an experienced LPN/LVN to perform pre-service and post-service utilization reviews and appeals for DMEPOS within an NCQA-compliant UM program.

The UM Nurse will collaborate with our Medical Director to assess medical necessity, apply criteria such as InterQual and CMS guidelines, and manage pre-authorization and denial letter processes. Remote opportunities may be available across the United States.

Qualifications

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

Responsibilities

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

Skills

LPN/LVN license

UM nursing experience

Collaboration with Medical Director

Education

LPN/LVN nursing diploma

Tools

InterQual

CMS guidelines

NCQA standards

Job description

Integra Partners is seeking an experienced LPN/LVN to perform pre-service and post-service utilization reviews and appeals for DMEPOS within an NCQA-compliant UM program.

The UM Nurse will collaborate with our Medical Director to assess medical necessity, apply criteria such as InterQual and CMS guidelines, and manage pre-authorization and denial letter processes. Remote opportunities may be available across the United States.