UM Nurse LPN — Managed Care Utilization & Appeals (Remote)

Integra Partners; Idaho; Remote; USD 42,000 - 64,000; Full time

Benefits offered by this job

Competitive pay

Annual bonus

401(k) match

Life insurance

Disability coverage

Health, Vision, Dental

Paid holidays

Wellness programs

Remote opportunities

Job summary

Integra Partners is seeking a Licensed Practical Nurse (LPN/LVN) with experience in managed care payor environments to perform pre-service and post-service utilization reviews and appeals for DMEPOS. The role collaborates with our Medical Director on benefit and medical necessity reviews within an NCQA-compliant UM program.

The UM Nurse will perform reviews, approve eligible requests, refer non-qualifying cases to the Medical Director, and handle administrative and clinical appeals while

Qualifications

• Active, licensed LVN/LPN in good standing.
• Minimum of 3 years nursing in an acute or outpatient setting.
• Minimum of 2 years UM experience in a managed care environment.
• Experience with medical necessity criteria (InterQual, CMS, policies).
• Experience writing denial letters preferred.

Responsibilities

• Perform pre-service and post-service UM authorization reviews using 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 such as NCQA, CMS and State agencies.

Skills

LPN/LVN license

UM experience

Medical necessity criteria

Denial letters

Job description

Integra Partners is seeking a Licensed Practical Nurse (LPN/LVN) with experience in managed care payor environments to perform pre-service and post-service utilization reviews and appeals for DMEPOS. The role collaborates with our Medical Director on benefit and medical necessity reviews within an NCQA-compliant UM program.

The UM Nurse will perform reviews, approve eligible requests, refer non-qualifying cases to the Medical Director, and handle administrative and clinical appeals while