UM Nurse LPN - Remote Utilization & Appeals Expert

Integra Partners; Milton (MA); A distancia; USD 70.000 - 98.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Annual bonus

401(k) with company match

Company-paid life insurance

Short-term disability insurance

Medical, Vision, and Dental benefits

Paid holidays and floating holidays

Health and wellness programs

Remote opportunities

Descripción de la vacante

Integra Partners is seeking a Licensed Practical Nurse to perform pre-service and post-service utilization management reviews and appeals within a NCQA-compliant UM program. You will collaborate with the Medical Director to assess medical necessity, benefits, and policy criteria for DMEPOS services across payor environments.

The role requires an active LPN/LVN license, at least 3 years of nursing in acute or outpatient settings, and 2+ years in managed care UM.

Formación

• Active LPN/LVN license
• Minimum 3 years nursing in acute or outpatient setting
• Minimum 2 years UM experience in a managed care payor environment
• Experience with InterQual and CMS guidelines and health plan medical policies
• Experience writing denial letters is preferred

Responsabilidades

• Perform pre-service and post-service UM authorization reviews using federal/state mandates, plan benefit language, and criteria for medical necessity
• Approve requests that meet eligibility, benefit, and medical necessity criteria
• Refer cases to Medical Director when criteria not met
• Process administrative and clinical appeals and refer as needed
• Maintain compliance with accrediting standards (NCQA, CMS, state agencies)

Conocimientos

UM experience in managed care

medical necessity criteria

denial letters experience

Educación

LPN/LVN license

Descripción del empleo

Integra Partners is seeking a Licensed Practical Nurse to perform pre-service and post-service utilization management reviews and appeals within a NCQA-compliant UM program. You will collaborate with the Medical Director to assess medical necessity, benefits, and policy criteria for DMEPOS services across payor environments.

The role requires an active LPN/LVN license, at least 3 years of nursing in acute or outpatient settings, and 2+ years in managed care UM.