Clinical Denials/Appeals RN

Job Family :

Clinical Appeals Nurse

Travel Required :

None

Clearance Required :

None

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:

• ​Review denials based on CARC code to determine root cause

• 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 update 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

• Bachelor’s Degree (Relevant experience may be substituted for formal education or advanced degree)

• 4+ years of clinical experience

What Would Be Nice To Have

• Utilization management experience

The annual salary range for this position is $74000.00-$124000.00. 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.

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 [email protected] . All information you provide will be kept confidential and will be used only to the extent required to provide needed reasonable accommodation.

All communication regarding recruitment for a Guidehouse position will be sent from Guidehouse email domains including @guidehouse.com or [email protected] .  Correspondence received by an applicant from any other domain should be considered unauthorized and will not be honored by Guidehouse.  Note that Guidehouse will never charge a fee or require a money transfer at any stage of the recruitment process and does not collect fees from educational institutions for participation in a recruitment event. Never provide your banking information to a third party purporting to need that information to proceed in the hiring process.

If any person or organization demands money related to a job opportunity with Guidehouse please report the matter to Guidehouse’s Ethics Hotline. If you want to check the validity of correspondence you have received please contact [email protected] . Guidehouse is not responsible for losses incurred (monetary or otherwise) from an applicant’s dealings with unauthorized third parties.

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.