About the role
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