UM Nurse LPN/LVN - Managed Care Utilization & Appeals

Integra Partners; Lexington (KY); Remote; USD 60,000 - 90,000; Full time

Benefits offered by this job

401(k) retirement plan with company 匹配

Company-paid life insurance

Company-paid short term disability

Medical, Vision, and Dental benefits

Paid company holidays

Health and wellness programs

Remote opportunities

Job summary

Integra Partners seeks an LPN/LVN experienced in managed care to perform pre-service and post-service utilization reviews and appeals for DMEPOS. You will collaborate with our Medical Director to conduct benefit and medical necessity reviews within an NCQA-compliant UM program, ensuring care is appropriate and benefits align with plan policies.

The role requires an active LPN/LVN license, a minimum of 3 years nursing experience, and at least 2 years in UM within a payor environment.

Qualifications

• Active, Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) license.
• 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 Medical Necessity Criteria including InterQual, CMS guidelines, health plan policies.

Responsibilities

• Perform pre-service and post-service UM authorization reviews using mandates and plan language to assess medical necessity.
• Approve requests that meet eligibility, benefit, and medical necessity criteria.
• Refer cases to 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 NCQA, CMS and State accreditation standards.

Skills

LPN/LVN license

UM experience

InterQual

CMS guidelines

Job description

Integra Partners seeks an LPN/LVN experienced in managed care to perform pre-service and post-service utilization reviews and appeals for DMEPOS. You will collaborate with our Medical Director to conduct benefit and medical necessity reviews within an NCQA-compliant UM program, ensuring care is appropriate and benefits align with plan policies.

The role requires an active LPN/LVN license, a minimum of 3 years nursing experience, and at least 2 years in UM within a payor environment.