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
Experience: 3 years required