Utilization Management Nurse - LPN/LVN

Summary

Join Integra Partners as an LPN/LVN in managed care, performing pre-service and post-service utilization reviews and appeals for DMEPOS. Collaborate with the Medical Director on benefit and medical necessity reviews within an NCQA-compliant UM program. This key role requires strong organizational skills and the ability to adapt in a fast-paced environment. The position offers competitive compensation, including an annual bonus program and comprehensive benefits. Integra values teamwork and offers remote opportunities in various states. Apply today to join our dedicated team and contribute to improving in-home healthcare.

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
• Verbal and written communication skills to convey information clearly and consistently

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
• 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

Preferred Qualifications

• Experience with Medicare and Medicaid
• Experience with UM authorizations and appeals for DMEPOS
• Experience with Medical Necessity Criteria including but not limited to InterQual, CMS guidelines, health plan medical policies, etc
• Experience writing denial letters

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
• Remote Opportunities