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 and medical necessity criteria.

Key responsibilities

• Conduct pre-service and post-service UM authorization reviews based on federal and state mandates and benefit language
• Communicate outcomes of UM authorization reviews and process administrative and clinical appeals as needed
• Maintain compliance with accrediting agency standards and collaborate with non-clinical teams to gather necessary clinical information

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 such as InterQual and CMS guidelines
• Experience with UM authorizations and appeals for DMEPOS is highly desirable