LPN Utilization Management Nurse

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