Utilization Management Nurse - LPN/LVN

Integra Partners•Troy, MI

3d•$60,000•Remote

About The Position

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 EDUCATION: Active, Licensed Vocational Nurse, or Licensed Practical Nurse license EXPERIENCE: 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

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 Medical Necessity Criteria including but not limited to InterQual, CMS guidelines, health plan medical policies, etc.
Verbal and written communication skills to convey information clearly and consistently

Nice To Haves

Experience with Medicare and Medicaid (not required, but highly desirable)
Experience with UM authorizations and appeals for DMEPOS (not required, but highly desirable)
Experience writing denial letters is preferred

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