UM Nurse LPN - Remote Care Management & Appeals

Integra Partners; Central City (KY); Remote; USD 70,000 - 100,000; Full time

Benefits offered by this job

401(k) retirement program with company

Company-paid life insurance

Company-paid short term disability

Medical, Vision, and Dental benefits

Paid company holidays and floating,

Health and wellness programs

Remote Opportunities

Job summary

Integra Partners is seeking an experienced LPN/LVN to perform pre-service and post-service utilization reviews and appeals within a NCQA-compliant UM program. The role collaborates with the Medical Director on benefit and medical necessity reviews in a managed care payor environment.

The UM Nurse will conduct reviews, approve eligible requests, refer non-eligible cases, and handle appeals while maintaining regulatory compliance and documentation standards.

Qualifications

• Active, Licensed Vocational Nurse, or Licensed Practical Nurse 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 but not limited to InterQual, CMS guidelines, health plan medical policies, etc.
• Experience writing denial letters is preferred.

Responsibilities

• Perform pre-service and post service UM authorization reviews utilizing 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 compliancewith all accrediting agency standards such as NCQA, CMS and State agencies.

Skills

LPN/LVN license

UM experience in managed care

Nursing in acute/outpatient

Medical necessity criteria (InterQual,

Education

Nursing degree (LPN/LVN track)

Job description

Integra Partners is seeking an experienced LPN/LVN to perform pre-service and post-service utilization reviews and appeals within a NCQA-compliant UM program. The role collaborates with the Medical Director on benefit and medical necessity reviews in a managed care payor environment.

The UM Nurse will conduct reviews, approve eligible requests, refer non-eligible cases, and handle appeals while maintaining regulatory compliance and documentation standards.