Integra is looking for a LPN/LVN experienced in the managed care payor environment to perform pre-service and post-service utilization reviews and appeals for DMEPOS. This individual will play a key role in collaborating with our Medical Director to perform benefit and medical necessity reviews and appeals within an NCQA-compliant UM program. The UM Nurse’s responsibilities include but are not limited to: 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 Approve requests that meet eligibility, benefit, and medical necessity criteria Refer cases to the Medical Director that do not meet medical necessity criteria Process administrative and clinical appeals and refer as needed to the Medical Director Maintain compliancewith 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 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 writing denial letters is preferred Benefits: Competitive compensation and annual bonus program 401(k) retirement program with company match Company-paid life insurance Company-paid short term disability coverage (location restrictions may apply) Medical, Vision, and Dental benefits Paid company holidays and floating holidays Health and wellness programs Remote Opportunities Founded in 2005, Integra Partners is a leading national durable medical equipment, prosthetic, and orthotic supplies (DMEPOS) network administrator. Our mission is to improve the quality of life for the communities we serve by reimagining access to in-home healthcare. We connect Payers, Providers, and Members through innovative technology and streamlined workflows affording Members access to top local Providers and culturally competent care. By focusing on transparency, accountability, and adaptability, we help deliver better health outcomes and more efficient management of complex healthcare benefits. With a location in Michigan plus a remote workforce across the United States, Integra has a culture focused on collaboration, teamwork, and our values: One Team, Drive Results, Push the Boundaries, Value Others, and Build Community. there may be a role for you to engage in a challenging yet rewarding career in healthcare. If you are a person with a disability and require assistance during the application process, please don’t hesitate to reach out. #J-18808-Ljbffr