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.
What You Will Need:- Current unrestricted Registered Nurse license in the state you reside
- Bachelor's degree and 4-6 years of prior relevant experience in acute care clinical experience in hospital setting or Associates Degree and 6-8 years of prior relevant experience in acute care clinical experience in hospital setting (Relevant experience may be substituted for formal education or advanced degree).
- Experience in clinical denials, utilization review, case management, or appeals required
What Would Be Nice To Have:- Bachelor of Science in Nursing
- Master's degree in Nursing
- Experience with InterQual and/or Milliman Care Guidelines, and electronic medical record systems.
- Compact State RN License
- Experience with inpatient level-of-care denials, DRG downgrades, and CMS payer rules.
- Strong knowledge of hospital revenue cycle workflows, medical necessity review, and payer regulations.
- Excellent analytical, organizational, and written communication skills with the ability to independently manage multiple cases.
#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
