A company is looking for a Utilization Management Nurse - LPN/LVN experienced in the managed care payor environment to perform pre-service and post-service utilization reviews and appeals for DMEPOS.
- 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
- Refer cases to the Medical Director that do not meet medical necessity criteria and refer cases to independent consultants or IROs, when necessary
- Process administrative and clinical appeals and maintain compliance with all accrediting agency standards such as NCQA, CMS and State agencies
- Active, Licensed Vocational Nurse, or Licensed Practical Nurse license
- Minimum of 3 years of nursing in an acute or outpatient setting and minimum of 2 years of UM experience in a managed care, payor environment
- Experience with Medical Necessity Criteria including but not limited to InterQual, CMS guidelines, health plan medical policies, etc
- Experience with Medicare and Medicaid (not required, but highly desirable) and experience with UM authorizations and appeals for DMEPOS (not required, but highly desirable)