UM Nurse (LPN/LVN) — DMEPOS Appeals & Medical Necessity

Integra Partners; Virginia; Remote; USD 30,000 - 60,000; Full time

Benefits offered by this job

Competitive compensation

Annual bonus program

401(k) retirement program with company

Company-paid life insurance

Short-term disability coverage

Medical, Vision, and Dental benefits

PTO

Paid parental leave

Sick time

Paid holidays and floating holidays

Quarterly events

Health and wellness programs

Career development opportunities

Job summary

Integra Partners seeks an LPN/LVN with managed care UM experience to perform pre-service and post-service utilization reviews and appeals for DMEPOS. You will collaborate with the Medical Director on benefit and medical necessity reviews within an NCQA-compliant UM program.

Salary: $60,000.00 annually. The role requires strong communication, coordination with cross-functional teams, and adherence to regulatory standards. Remote opportunities are available across multiple states.

Qualifications

• Minimum of 3 years of nursing in an acute or outpatient setting.
• Minimum of 2 years of UM experience in a managed care, payor environment.
• Experience with Medicare and Medicaid desirable.
• Experience with UM authorizations and appeals for DMEPOS desirable.
• Experience with Medical Necessity Criteria (e.g., InterQual, CMS policies).
• Experience writing denial letters preferred.

Responsibilities

• Perform pre-service and post-service UM authorization reviews using federal/state mandates and plan language.
• Collaborate with non-clinical team to obtain information as needed.
• Approve requests meeting eligibility, benefit and medical necessity criteria.
• Refer cases not meeting criteria to Medical Director or IROs as needed.
• Communicate outcomes of UM reviews verbally and in writing.
• Process administrative and clinical appeals with Medical Director oversight.
• Maintain NCQA, CMS and state accrediting standards compliance.

Skills

UM reviews

Medical necessity criteria

Documentation/communication

Collaboration with Medical Director

Adaptability

Education

LPN/LVN license

Job description

Integra Partners seeks an LPN/LVN with managed care UM experience to perform pre-service and post-service utilization reviews and appeals for DMEPOS. You will collaborate with the Medical Director on benefit and medical necessity reviews within an NCQA-compliant UM program.

Salary: $60,000.00 annually. The role requires strong communication, coordination with cross-functional teams, and adherence to regulatory standards. Remote opportunities are available across multiple states.