UM Nurse LPN - Remote Utilization Review & Appeals

Integra Partners; Eagle (ID); Remote; USD 60,000 - 85,000; Full time

Benefits offered by this job

Competitive compensation and annualbon

401(k) retirement with company match

Company-paid life insurance

Company-paid short term disability

Medical, Vision, and Dental benefits

Paid holidays and floating holidays

Health and wellness programs

Remote Opportunities

Job summary

Integra Partners is seeking an LPN/LVN with managed care UM experience to perform pre- and post-service utilization reviews and appeals for DMEPOS. You will collaborate with our Medical Director to assess benefit and medical necessity within an NCQA-compliant UM program.

Responsibilities include reviewing criteria, approving eligible requests, and referring complex cases to the Medical Director. The role requires active licensure and several years of nursing and UM experience in a payor

Qualifications

• Active LPN or LVN license required.
• Minimum of 3 years of nursing in an acute or outpatient setting.
• Minimum of 2 years of UM experience in a managed care environment.
• Experience with medical necessity criteria such as InterQual or CMS policies.
• Experience writing denial letters preferred.

Responsibilities

• Perform pre-service and post-service UM reviews using federal/state mandates, plan benefits, and criteria for medical necessity.
• Approve requests that meet eligibility and medical necessity criteria.
• Refer cases to Medical Director for non-acceptable cases or for complex decisions.
• Process administrative and clinical appeals as needed.
• Maintain compliance with NCQA, CMS and state accrediting standards.

Skills

UM experience

Nursing background

Medical necessity criteria

Education

LPN/LVN license

Job description

Integra Partners is seeking an LPN/LVN with managed care UM experience to perform pre- and post-service utilization reviews and appeals for DMEPOS. You will collaborate with our Medical Director to assess benefit and medical necessity within an NCQA-compliant UM program.

Responsibilities include reviewing criteria, approving eligible requests, and referring complex cases to the Medical Director. The role requires active licensure and several years of nursing and UM experience in a payor