UM Nurse LPN — Managed Care Appeals (Remote)

Integra Partners; Illinois; Remote; USD 70,000 - 90,000; Full time

Benefits offered by this job

Competitive compensation

401(k) with company match

Company-paid life insurance

Remote opportunities

Medical, Vision, Dental

Job summary

Integra Partners seeks an experienced LPN/LVN to perform pre-service and post-service utilization reviews and appeals in a NCQA-compliant UM program. The role collaborates with the Medical Director to assess medical necessity and benefit coverage for DMEPOS.

Required are a current LPN/LVN license, 3+ years nursing in acute/outpatient care, and 2+ years UM in managed care. Prior experience with InterQual and CMS guidelines is valued; denial letters are often written.

Qualifications

• Active LPN/LVN license required.
• Minimum 3 years of nursing in acute or outpatient settings.
• Minimum 2 years of UM experience in managed care/payor environment.
• Experience with Medical Necessity Criteria (InterQual, CMS guidelines, plan policies).
• Experience writing denial letters preferred.

Responsibilities

• Perform pre-service and post-service UM reviews for medical necessity.
• Approve requests that meet eligibility and benefit criteria.
• Refer cases to Medical Director when criteria are not met.
• Process administrative and clinical appeals and escalate as needed.
• Maintain compliance with NCQA/CMS/state standards.
• Collaborate with Medical Director in UM program.

Skills

LPN/LVN license

UM experience

Medical necessity criteria

DMEPOS knowledge

Job description

Integra Partners seeks an experienced LPN/LVN to perform pre-service and post-service utilization reviews and appeals in a NCQA-compliant UM program. The role collaborates with the Medical Director to assess medical necessity and benefit coverage for DMEPOS.

Required are a current LPN/LVN license, 3+ years nursing in acute/outpatient care, and 2+ years UM in managed care. Prior experience with InterQual and CMS guidelines is valued; denial letters are often written.