Job Family:
Clinical Appeals Nurse
Travel Required:
None
Clearance Required:
None
What You Will Do:
- Conduct pre‑ and post‑service medical necessity reviews for inpatient, observation, and outpatient hospital encounters using evidence‑based criteria such as InterQual and Milliman Care Guidelines.
- Perform retrospective medical record reviews to validate completeness and accuracy of physician and clinical documentation supporting level of care and services rendered.
- Identify denial root causes and determine appeal viability based on payer policies, regulatory guidance, and clinical standards.
- Prepare, submit, and track clinical appeals, including written appeals.
- Collaborate with Patient Access, Case Management, Utilization Management, Coding, and Mid‑Revenue Cycle teams to resolve denials and prevent recurrence.
- Research and apply payer‑specific policies, CMS regulations, and contractual language to support appeal arguments.
- Track and report denial and appeal outcomes, identify trends, and provide recommendations for process improvement and staff education.
- Maintain accurate documentation of all review activities in hospital and payer systems in accordance with compliance standards.
- Excellent analytical, organizational, and written communication skills with the ability to independently manage multiple cases.
- Strong working knowledge of hospital revenue cycle workflows, medical necessity review, and payer regulations..
What You Will Need:
- Current unrestricted Registered Nurse license in the state you reside. (Compact license preferred)
- Minimum of five years of acute care clinical experience in a hospital setting.
- Prior experience in clinical denials, utilization review, case management, or appeals required.
What Would Be Nice To Have:
- Bachelor of Science in Nursing required; master’s degree in nursing
- Experience with inpatient level‑of‑care denials, DRG downgrades, and CMS payer rules
- Proficiency with InterQual, Milliman Care Guidelines, and electronic medical record systems
#LI-DNI
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
