LPN Utilization Management Nurse

Job Summary

To support a managed care environment, the full-time LPN Utilization Management Nurse will perform pre-service and post-service utilization reviews and appeals for DMEPOS, collaborating with the Medical Director to ensure compliance with NCQA standards while working remotely.

Key responsibilities

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

Required qualifications

• Active Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) license
• A 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 payor environment
• Familiarity with Medical Necessity Criteria and experience with UM authorizations and appeals for DMEPOS is preferred
• Experience writing denial letters is preferred