Clinical Denials and Appeals RN id-9784

May 30, 2025

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

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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

Requires a Bachelor’s Degree (Relevant experience may be substituted for formal education or advanced degree).
Current Registered Nursing License.
Minimum 4-6 years of prior clinical experience

What Would Be Nice To Have

Utilization Review experience a plus

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The annual salary range for this position is $68,000.00-$113,000.00. Compensation decisions depend on a wide range of factors, including but not limited to skill sets, experience and training, security clearances, licensure and certifications, and other business and organizational needs.

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 Opportunity Employer–Protected Veterans, Individuals with Disabilities 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.

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