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

Integra Partners; Michigan; Remote; USD 54,000 - 66,000; Full time

Benefits offered by this job

Competitive compensation

401(k) retirement program with company

Company-paid life insurance

Company-paid short term disability

Medical, Vision, and Dental benefits

PTO

Parental Leave

Sick Time

Paid holidays

Wellness programs

Career development opportunities

Job summary

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

This role requires 3+ years of nursing experience, 2+ years in UM, and strong communication skills. The position offers competitive compensation, comprehensive benefits, and opportunities for professional

Qualifications

• Active, Licensed Practical Nurse (LPN/LVN) license required.
• 3+ years of nursing in acute or outpatient settings.
• 2+ years of UM experience in managed care/payor environment.
• Experience with Medicare/Medicaid is desirable.
• Experience with UM authorizations and appeals for DMEPOS is desirable.
• Strong verbal and written communication skills.

Responsibilities

• Perform pre-service and post-service UM authorization reviews using federal/state mandates, plan benefit language and criteria for medical necessity.
• Collaborate with non-clinical team to obtain additional clinical information as needed.
• Approve requests that meet eligibility, benefit, and medical necessity criteria.
• Refer cases to Medical Director or independent consultants/IROs when necessary.
• Communicate outcomes of UM reviews verbally and in writing.
• Process administrative and clinical appeals and refer as needed to Medical Director.
• Maintain compliance with NCQA, CMS and state accrediting standards.
• Demonstrate strong organizational skills and adaptability in a fast-paced environment.

Skills

UM knowledge

Nursing license

Communication skills

Organizational skills

Team player

Education

LPN/LVN license

Tools

InterQual guidelines

CMS guidelines

Job description

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

This role requires 3+ years of nursing experience, 2+ years in UM, and strong communication skills. The position offers competitive compensation, comprehensive benefits, and opportunities for professional