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

Integra Partners; Kentucky; Remote; USD 65,000 - 80,000; Full time

Benefits offered by this job

Competitive compensation based on 3+%?

401(k) retirement program with company

Company-paid life insurance

Short term disability coverage

Medical, Vision, and Dental benefits

Paid holidays

Health and wellness programs

Remote opportunities

Job summary

Integra Partners is seeking a licensed practical nurse (LPN/LVN) experienced in the managed care payor environment to perform pre-service and post-service utilization reviews and appeals for DMEPOS. The role collaborates with the Medical Director on benefit and medical necessity decisions within an NCQA-compliant UM program.

The UM Nurse will conduct reviews, approve eligible requests, and refer non-qualifying cases.

Qualifications

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

Responsibilities

• Perform pre-service and post-service UM authorization reviews utilizing federal and state mandates, plan benefit language and criteria for medical necessity.
• 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 to the Medical Director.
• Maintain compliance with accrediting standards such as NCQA, CMS and State agencies.

Skills

Nursing

UM experience

LPN/LVN licensure

Medical necessity reviews

Denied letters writing

Education

LPN/LVN license

Job description

Integra Partners is seeking a licensed practical nurse (LPN/LVN) experienced in the managed care payor environment to perform pre-service and post-service utilization reviews and appeals for DMEPOS. The role collaborates with the Medical Director on benefit and medical necessity decisions within an NCQA-compliant UM program.

The UM Nurse will conduct reviews, approve eligible requests, and refer non-qualifying cases.