Utilization Management Nurse - LPN/LVN
About the job
- Hold an active Licensed Vocational Nurse or Licensed Practical Nurse license.
- Have at least 3 years of nursing experience in an acute or outpatient setting.
- Have at least 2 years of utilization management experience in a managed care or payer environment.
- Have experience with medical necessity criteria, including InterQual, Centers for Medicare & Medicaid Services guidelines, and health plan medical policies.
- Have verbal and written communication skills to convey information clearly and consistently.
- Have organizational skills and the ability to adapt quickly to change in a fast-paced environment.
- Be team-oriented and self-motivated.
- Perform pre-service and post-service utilization management authorization reviews using federal and state mandates, plan benefit language, and National and Local Coverage Determinations as criteria for medical necessity reviews.
- Work with the non-clinical team to obtain additional clinical information as needed.
- Approve requests that meet eligibility, benefit, and medical necessity criteria.
- Refer cases that do not meet medical necessity criteria to the Medical Director.
- Refer cases to independent consultants or independent review organizations when necessary.
- Communicate the outcomes of utilization management authorization reviews verbally and in writing.
- Process administrative and clinical appeals and refer them to the Medical Director as needed.
- Maintain compliance with accrediting agency standards, including National Committee for Quality Assurance, Centers for Medicare & Medicaid Services, and state agencies.
- Perform other duties as assigned.
- Experience with Medicare and Medicaid.
- Experience with utilization management authorizations and appeals for durable medical equipment, prosthetics, orthotics, and supplies.
- Experience writing denial letters.
About the company
Integra Partners connects durable medical equipment, prosthetics, orthotics, and supplies providers with health plans to improve access to care. It acts as an intermediary using a network and platform that allows providers, insurers, and members to interact more efficiently, enabling smarter access to DMEPOS services. Revenue comes from service fees charged to providers and health plans for using Integra's network and platform. The company emphasizes compliance with healthcare privacy and security regulations to protect PHI. Unlike general healthcare intermediaries, Integra Partners focuses on the DMEPOS sector and on delivering local quality care through a compliant network, aiming to streamline interactions and improve care delivery.
Company Size
201-500
Company Stage
N/A
Total Funding
N/A
Headquarters
New York City, New York
Founded
2005
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Simplify's Take
What believers are saying
- Healthfirst expanded Integra's prior-authorization role across all plans starting June 1, 2026.
- Independent Health hired Integra for DME network administration across Commercial, Medicare, State Programs.
- HelixVM partnership launched December 2025, creating faster documentation capture for DMEPOS providers.
What critics are saying
- Healthfirst shifted all DMEPOS prior authorizations to Integra on June 1, 2026, creating contract dependence.
- Independent Health noted some DMEPOS suppliers will not join Integra's network on April 1, 2026.
- Any payer insourcing or vendor switch in 2027 would erase Integra's utilization-management revenue.
What makes Integra Partners unique
- Integra Partners controls DMEPOS network management across 60 payer lines, per January 2026.
- Its portal turns prior authorizations into a centralized workflow for plans and suppliers.
- HelixVM integration links telehealth documentation directly to DMEPOS orders, accelerating reimbursement.
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Benefits
- Health Insurance
- Vision Insurance
- Dental Insurance
- Life Insurance
- Disability Insurance
- Remote Work Options
- Paid Time Off
- Paid Parental Leave
- Sick Time
- Paid Holidays
- 401(k) Retirement Plan
- 401(k) Company Match