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Utilization Management Nurse – LPN/LVN, Multistate
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 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
- 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
- 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
