[Hiring] Utilization Management Nurse - LPN/LVN @Integra Partners

Role 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.

Qualifications

• 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
• 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

Requirements

• 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

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