Clinical Denial Nurse

Dovel Technologies, Inc; Northern (KY); Hybrid; USD 68,000 - 113,000; Full time

Benefits offered by this job

Medical Insurance

Dental & Vision

401(k)

Job summary

Guidehouse is seeking a Clinical Appeals Nurse to conduct medical necessity reviews for inpatient and outpatient encounters, ensuring compliance with InterQual and CMS guidance. You will lead denial analyses, prepare appeals, and collaborate with Revenue Cycle teams to resolve cases.

Qualifications include RN license, 5+ years acute care, and experience in denials or utilization review; BSN preferred. This is a non-travel, full-time role with comprehensive benefits.

Qualifications

• Current unrestricted RN license in the state of residence.
• Minimum of five years of acute care hospital experience.
• Experience in clinical denials, utilization review, case management, or appeals.

Responsibilities

• Conduct medical necessity reviews for inpatient, observation, and outpatient encounters using evidence‑based criteria.
• Identify denial root causes and determine appeal viability based on payer policies and clinical standards.
• Prepare, submit, and track clinical appeals and written appeals.
• Collaborate with Revenue Cycle teams to resolve denials and prevent recurrence.
• Research payer policies and CMS regulations to support appeal arguments.
• Maintain accurate documentation in hospital and payer systems per compliance standards.

Skills

Clinical denials

Utilization review

Appeals

Acute care nursing

Medical record review

Education

Bachelor of Science in Nursing

Tools

InterQual

Milliman Care Guidelines

EMR systems

Job description

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

Salary

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.

Benefits

• 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 your 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 [e-mail].

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 [e-mail]. Correspondence received by an applicant from any other domain should be considered unauthorized and will not be honored by Guidehouse.

Guidehouse is a global AI‑led professional services firm delivering advisory, technology, and managed services to the commercial and government sectors. With an integrated business technology approach, Guidehouse drives efficiency and resilience in the healthcare, financial services, energy, infrastructure, and national security markets. Built to help clients across industries outwit complexity, the firm brings together approximately 18,000 professionals to achieve lasting impact and shape a meaningful future. guidehouse.com