Utilization Management Nurse - LPN/LVN
About the position
Integra Partners is seeking a Utilization Management Nurse (LPN/LVN) to conduct pre-service and post-service utilization reviews and appeals for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS). This role involves collaboration with the Medical Director to ensure compliance with NCQA standards while assessing medical necessity and benefit eligibility.
Responsibilities
Ā 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.
,
Ā Work with non-clinical team to obtain additional clinical information as needed.
,
Ā Approve requests that meet eligibility, benefit, and medical necessity criteria.
,
Ā Refer cases to the Medical Director that do not meet medical necessity criteria.
,
Ā Refer cases to independent consultants or IROs when necessary.
,
Ā Communicate outcomes of UM authorization reviews, both verbally and in writing.
,
Ā Process administrative and clinical appeals and refer as needed to the Medical Director.
,
Ā Maintain compliance with all accrediting agency standards such as NCQA, CMS, and State agencies.
,
Ā Perform other duties as assigned.
Requirements
Ā Active, Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) license.
,
Ā Minimum of 3 years of nursing experience in an acute or outpatient setting.
,
Ā Minimum of 2 years of Utilization Management experience in a managed care, payor environment.
,
Ā Experience with Medical Necessity Criteria including InterQual, CMS guidelines, and health plan medical policies.
Nice-to-haves
Ā Experience with Medicare and Medicaid (not required, but highly desirable).
,
Ā Experience with UM authorizations and appeals for DMEPOS (not required, but highly desirable).
,
Ā Experience writing denial letters is preferred.
Benefits
Ā Competitive compensation and annual bonus program
,
Ā 401(k) retirement program with company match
,
Ā Company-paid life insurance
,
Ā Company-paid short term disability coverage
,
Ā Medical, Vision, and Dental benefits
,
Ā Paid Time Off (PTO)
,
Ā Paid Parental Leave
,
Ā Sick Time
,
Ā Paid company holidays and floating holidays
,
Ā Quarterly company-sponsored events
,
Ā Health and wellness programs
,
Ā Career development opportunities
Apply Now
Integra Partners is seeking a Utilization Management Nurse (LPN/LVN) to conduct pre-service and post-service utilization reviews and appeals for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS). This role involves collaboration with the Medical Director to ensure compliance with NCQA standards while assessing medical necessity and benefit eligibility.
Responsibilities
Ā 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.
,
Ā Work with non-clinical team to obtain additional clinical information as needed.
,
Ā Approve requests that meet eligibility, benefit, and medical necessity criteria.
,
Ā Refer cases to the Medical Director that do not meet medical necessity criteria.
,
Ā Refer cases to independent consultants or IROs when necessary.
,
Ā Communicate outcomes of UM authorization reviews, both verbally and in writing.
,
Ā Process administrative and clinical appeals and refer as needed to the Medical Director.
,
Ā Maintain compliance with all accrediting agency standards such as NCQA, CMS, and State agencies.
,
Ā Perform other duties as assigned.
Requirements
Ā Active, Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) license.
,
Ā Minimum of 3 years of nursing experience in an acute or outpatient setting.
,
Ā Minimum of 2 years of Utilization Management experience in a managed care, payor environment.
,
Ā Experience with Medical Necessity Criteria including InterQual, CMS guidelines, and health plan medical policies.
Nice-to-haves
Ā Experience with Medicare and Medicaid (not required, but highly desirable).
,
Ā Experience with UM authorizations and appeals for DMEPOS (not required, but highly desirable).
,
Ā Experience writing denial letters is preferred.
Benefits
Ā Competitive compensation and annual bonus program
,
Ā 401(k) retirement program with company match
,
Ā Company-paid life insurance
,
Ā Company-paid short term disability coverage
,
Ā Medical, Vision, and Dental benefits
,
Ā Paid Time Off (PTO)
,
Ā Paid Parental Leave
,
Ā Sick Time
,
Ā Paid company holidays and floating holidays
,
Ā Quarterly company-sponsored events
,
Ā Health and wellness programs
,
Ā Career development opportunities
Apply Now