Utilization Management Nurse - LPN/LVN

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