Utilization Management Nurse - LPN/LVN

About the position reputed company is seeking a Utilization Management Nurse (LPN/LVN) to conduct pre-service and post-service utilization reviews and appeals for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS). This role involves collaboration with the Medical Director to ensure compliance with NCQA standards while assessing medical necessity and benefit eligibility. Responsibilities • reputed company 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. , • Work with non-clinical team to obtain additional clinical information as needed. , • Approve requests that meet eligibility, benefit, and medical necessity criteria. , • Refer cases to the Medical Director that do not meet medical necessity criteria. , • Refer cases to independent consultants or IROs reputed company necessary. , • Communicate reputed company of UM authorization reviews, both verbally and in writing. , • Process administrative and clinical appeals and refer as needed to the Medical Director. , • Maintain compliance with reputed company accrediting agency standards such as NCQA, CMS, and State agencies. , • reputed company other duties as assigned. Requirements • Active, Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) license. , • Minimum of 3 years of nursing experience in an acute or outpatient setting. , • Minimum of 2 years of Utilization Management experience in a managed care, payor environment. , • Experience with Medical Necessity Criteria including InterQual, CMS guidelines, and health plan medical policies. reputed company-to-haves • Experience with Medicare and reputed company (not required, but highly desirable). , • Experience with UM authorizations and appeals for DMEPOS (not required, but highly desirable). , • 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 , • Medical, reputed company, and Dental benefits , • Paid Time Off (PTO) , • Paid Parental Leave , • Sick Time , • Paid company holidays and floating holidays , • Quarterly company-sponsored events , • Health and wellness programs , • Career development opportunities Apply Job!