Clinical Denials and Appeals RN

Job Family:

Travel Required:

Clearance Required:

What You Will Do:

The Remote Clinical Denials/Appeals Nurse will be directly responsible for securing pre-service approvals, and reviewing pre/post service denials, medical necessity review and completing appeals and/or coordinating peer to peer reviews as appropriate. This position will perform all related job duties as assigned.

Essential Job Functions:

• Medical Necessity Reviews
• Ensure documentation integrity
• Construct warranted appeals
• Coordinate pre-service authorization approvals

Duties and Responsibilities:

• Conduct comprehensive Denial Root-cause analysis.
• Retrospective Medical Record reviews to assure complete and accurate physician/staff documentation is present to support medical necessity.
• Collaboration with hospital Patient Access and Mid-Revenue Cycle
• Utilize Evidence -based clinical guideline tool (Milliman ® or InterQual ®))
• Research and application of regulatory policies to support clinical appeal.
• Telephonic communication with payors, provider, hospital staff and patient/family as necessary to bring the account into resolution.
• Technical ability to multi-task on various systems, desktop and Microsoft applications while managing inbound calls.
• Working knowledge of basic Coding Guidelines.
• May be required to present oral presentations to client facility or Guidehouse staff and leadership

• Attention to detail, strong organizational skills and self-motivated.
• Ability to make decisions and assimilate multiple data sources or issues related to problem solving independently & accurately.
• Ability to work under a timeline/deadline & provide clear & accurate updates to project leader of assignment progress, hours worked & expected outcomes daily.
• Familiarity with medical records assembly & clinical terminology, coding terminology additionally beneficial.
• Personal responsibility, respect for self and others, innovation through teamwork, dedication to caring and excellence in customer service.

What You Will Need:

• Current Registered Nursing License.
• Minimum of 5 years clinical experience


What Would Be Nice To Have:

• Utilization Review experience a plus

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What We Offer:

Guidehouse offers a comprehensive, total rewards package that includes competitive compensation and a flexible benefits package that reflects our commitment to creating a diverse and supportive workplace.

Benefits include:

• Medical, Rx, Dental & Vision Insurance

• Personal and Family Sick Time & Company Paid Holidays

• Position may be eligible for a discretionary variable incentive bonus

• Parental Leave

• 401(k) Retirement Plan

• Basic Life & Supplemental Life

• Health Savings Account, Dental/Vision & Dependent Care Flexible Spending Accounts

• Short-Term & Long-Term Disability

• Tuition Reimbursement, Personal Development & Learning Opportunities

• Skills Development & Certifications

• Employee Referral Program

• Corporate Sponsored Events & Community Outreach

• Emergency Back-Up Childcare Program

About Guidehouse
Guidehouse is an Equal Employment Opportunity / Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, citizenship status, military status, protected veteran status, religion, creed, physical or mental disability, medical condition, marital status, sex, sexual orientation, gender, gender identity or expression, age, genetic information, or any other basis protected by law, ordinance, or regulation.

Guidehouse will consider for employment qualified applicants with criminal histories in a manner consistent with the requirements of applicable law or ordinance including the Fair Chance Ordinance of Los Angeles and San Francisco.

If you have visited our website for information about employment opportunities, or to apply for a position, and you require an accommodation, please contact Guidehouse Recruiting at 1-571-633-1711 or via email at RecruitingAccommodation@guidehouse.com. All information you provide will be kept confidential and will be used only to the extent required to provide needed reasonable accommodation.

Guidehouse does not accept unsolicited resumes through or from search firms or staffing agencies. All unsolicited resumes will be considered the property of Guidehouse and Guidehouse will not be obligated to pay a placement fee.