LPN Utilization Management Nurse

Job Summary

Collaborating with the Medical Director, the full-time remote LPN Utilization Management Nurse will perform pre-service and post-service utilization reviews and appeals for DMEPOS, ensuring compliance with NCQA standards.

Key responsibilities

• Conduct pre-service and post-service UM authorization reviews based on federal and state mandates and medical necessity criteria
• Work with non-clinical teams to gather additional clinical information and communicate review outcomes
• Process administrative and clinical appeals, referring cases to the Medical Director as necessary

Required qualifications

• Active Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) license
• Minimum of 3 years of nursing experience in an acute or outpatient setting
• At least 2 years of experience in Utilization Management within a managed care environment
• Familiarity with Medical Necessity Criteria, including InterQual and CMS guidelines
• Experience writing denial letters is preferred