Clinical Denials and Appeals RN

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