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

Integra Partners; New Jersey; Remote; USD 70,000 - 95,000; 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 seeks 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 benefit and medical necessity criteria and handle related appeals.

The role requires licensure as LPN/LVN, at least 3 years nursing experience, and 2+ years UM experience in managed care. Remote opportunities are available.

Qualifications

• Active Licensed Vocational Nurse or Licensed Practical Nurse license.
• Minimum 3 years of nursing experience in an acute or outpatient setting.
• Minimum 2 years of utilization management 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 using federal/state mandates and plan benefit language.
• Approve requests that meet eligibility, benefit, and medical necessity criteria.
• Refer cases to Medical Director if not meeting medical necessity criteria.
• Process administrative and clinical appeals and refer as needed.
• Maintain compliance with accrediting standards (NCQA, CMS, state agencies).

Skills

UM experience

Nursing experience

Medical Necessity Criteria (InterQual,

CMS guidelines

Ability to write denial letters

Education

LPN/LVN license

Job description

Integra Partners seeks 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 benefit and medical necessity criteria and handle related appeals.

The role requires licensure as LPN/LVN, at least 3 years nursing experience, and 2+ years UM experience in managed care. Remote opportunities are available.