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 in a remote setting.

Key responsibilities

• Conduct pre-service and post-service UM authorization reviews based on medical necessity criteria and plan benefit language
• Collaborate with non-clinical teams to gather necessary clinical information and communicate review outcomes
• Process administrative and clinical appeals, maintaining compliance with accrediting agency standards such as NCQA and CMS

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 payor environment
• Familiarity with Medical Necessity Criteria, including InterQual and CMS guidelines
• Experience with UM authorizations and appeals for DMEPOS is highly desirable