Remote Utilization Review Nurse (LPN/LVN)

Integra Partners; Florida; Remote; USD 65,000 - 90,000; Full time

Benefits offered by this job

Annual bonus

401k

Life insurance

Short term disability

Medical, Vision, and Dental benefits

Holidays & floating holidays

Wellness programs

Remote work

Job summary

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

Responsibilities include authorizing eligible requests, referring non-eligible cases to the Medical Director, handling appeals, and ensuring compliance with NCQA, CMS and state standards.

Qualifications

• Pre-service and post-service UM authorization reviews using applicable mandates and criteria.
• Approve requests meeting eligibility and medical necessity criteria.
• Refer cases not meeting criteria to Medical Director.
• Process administrative and clinical appeals as needed.

Responsibilities

• Perform pre-service and post service UM authorization reviews utilizing federal and state mandates, plan benefit language and NCDs/LCDs as 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 to the Medical Director
• Maintain compliance with accrediting standards (NCQA, CMS, State agencies)
• Active LPN/LVN license
• Minimum of 3 years nursing experience in acute or outpatient setting
• Minimum of 2 years UM experience in managed care/payor environment
• Experience with Medical Necessity Criteria (InterQual, CMS guidelines, etc)
• Experience writing denial letters preferred

Skills

Nursing experience

UM experience

Medical necessity review

Education

LPN/LVN license

Job description

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

Responsibilities include authorizing eligible requests, referring non-eligible cases to the Medical Director, handling appeals, and ensuring compliance with NCQA, CMS and state standards.