Integra Partners is hiring a
Utilization Management Nurse
Integra Partners
π΅ $60k
πRemote - Worldwide
Please let Integra Partners know you found this job on JobsCollider. Thanks! π
Summary
Join Integra Partners as an LPN/LVN experienced in managed care payor environment to perform pre-service and post-service utilization reviews and appeals for DMEPOS, collaborating with Medical Director to perform benefit and medical necessity reviews and appeals within an NCQA-compliant UM program.
Requirements
- 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
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
- 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 compliance with all accrediting agency standards such as NCQA, CMS and State agencies
Benefits
- 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
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