Utilization Management Nurse - LPN/LVN

Integra Partners; Michigan; Hybrid; USD 54,000 - 66,000; Full time

Benefits offered by this job

Annual bonus program

401(k) retirement program with company

Company-paid life insurance

Short term disability coverage

Medical, Vision, and Dental benefits

PTO

Paid Parental Leave

Sick Time

Holidays and floating holidays

Quarterly events

Wellness programs

Career development opportunities

Job summary

Integra Partners seeks an experienced LPN/LVN to perform pre-service and post-service utilization reviews and appeals within a NCQA-compliant UM program. You will collaborate with our Medical Director on benefit and medical necessity reviews in a managed care payor environment.

The role requires active LPN/LVN licensure, at least 3 years of nursing experience, and 2+ years in UM. The position offers competitive compensation with comprehensive benefits and potential annual bonus.

Qualifications

• 3+ years nursing in acute or outpatient setting required.
• 2+ years UM experience in managed care/payor environment desired.
• Familiarity with Medicare/Medicaid and UM authorizations helpful.
• Strong written and verbal communication skills.

Responsibilities

• Perform pre-service and post-service UM authorization reviews using mandates, plan benefits, and criteria for medical necessity.
• Coordinate with non-clinical teams to obtain needed information.
• Approve requests meeting eligibility, benefit, and medical necessity criteria.
• Refer cases not meeting criteria to Medical Director or independent consultants.
• Communicate outcomes of UM reviews both verbally and in writing.
• Process administrative and clinical appeals and refer as needed.
• Maintain NCQA CMS and state accrediting standards compliance.
• Demonstrate strong organization, adaptability, and teamwork.
• Perform other duties as assigned.

Skills

Nursing experience

UM experience

Medical terminology

Communication skills

Team collaboration

Education

Licensed Practical Nurse (LPN) license

Job description

Integra is looking for a LPN/LVN experienced in the managed care payor environment to perform pre-service and post-service utilization reviews and appeals for DMEPOS. This individual will play a key role in collaborating with our Medical Director to perform benefit and medical necessity reviews and appeals within an NCQA-compliant UM program.

Salary: $60,000.00/annual

JOB QUALIFICATIONS: KNOWLEDGE/SKILLS/ABILITIES

The UM Nurse’s responsibilities include but are not limited to:

• 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
• Work with non-clinical team to obtain additional clinical information, as needed
• Approve requests that meet eligibility, benefit, and medical necessity criteria
• Refer cases to the Medical Director that do not meet medical necessity criteria
• Refer cases to independent consultants or IROs, when necessary
• Communicate outcomes of UM authorization reviews, both verbally and in writing
• 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
• Strong organizational skills, ability to adapt quickly to change and desire to work in a fast-paced environment
• Team oriented and self-motivated with a positive attitude
• Performs other duties as assigned

EDUCATION:

Active, Licensed Vocational Nurse, or Licensed Practical Nurse license

EXPERIENCE:

• 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 Medicare and Medicaid (not required, but highly desirable)
• Experience with UM authorizations and appeals for DMEPOS (not required, but highly desirable)
• Experience with Medical Necessity Criteria including but not limited to InterQual, CMS guidelines, health plan medical policies, etc.
• Experience writing denial letters is preferred
• Verbal and written communication skills to convey information clearly and consistently

Benefits Offered

• Competitive compensation and annual bonus program
• 401(k) retirement program with company match
• Company-paid life insurance
• Company-paid short term disability coverage (location restrictions may apply)
• Medical, Vision, and Dental benefits
• Paid Time Off (PTO)
• Paid Parental Leave
• Sick Time
• Paid company holidays and floating holidays
• Quarterly company-sponsored events
• Health and wellness programs
• Career development opportunities

Remote Opportunities

We are actively seeking new colleagues in: Arizona, Colorado, Connecticut, Florida, Georgia, Idaho, Illinois, Kentucky, Massachusetts, Michigan, North Carolina, Nevada, New Jersey, New York, Ohio, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, and Washington.

Our Story

Founded in 2005, Integra Partners is a leading national durable medical equipment, prosthetic, and orthotic supplies (DMEPOS) network administrator. Our mission is to improve the quality of life for the communities we serve by reimagining access to in-home healthcare. We connect Payers, Providers, and Members through innovative technology and streamlined workflows affording Members access to top local Providers and culturally competent care. By focusing on transparency, accountability, and adaptability, we help deliver better health outcomes and more efficient management of complex healthcare benefits.

With a location in Michigan plus a remote workforce across the United States, Integra has a culture focused on collaboration, teamwork, and our values: One Team, Drive Results, Push the Boundaries, Value Others, and Build Community. We’re looking for energetic, talented, and dedicated individuals to join our team. See what opportunities we have available; there may be a role for you to engage in a challenging yet rewarding career in healthcare. We look forward to learning more about you.

Integra Partners is an equal opportunity employer. We are committed to providing reasonable accommodations and will work with you to meet your needs. If you are a person with a disability and require assistance during the application process, please don’t hesitate to reach out. We celebrate our inclusive work environment and welcome members of all backgrounds and perspectives.