Clinical Denial RN

US104 Guidehouse Managed Services LLC; Atlanta (GA); Hybride; USD 68 000 - 113 000; Plein temps

Avantages offerts par ce poste

Medical insurance

Dental & Vision Insurance

Paid Holidays

401(k) Retirement Plan

Tuition Reimbursement

Employee Referral Program

Résumé du poste

Guidehouse is seeking a Clinical Appeals Nurse to conduct pre- and post-service medical necessity reviews for inpatient, observation, and outpatient hospital encounters, using InterQual and Milliman criteria.

The role requires RN licensure and 6–8 years of acute care experience, with experience in denials, utilization review, or appeals; you will prepare and track appeals, collaborate across teams, and ensure documentation compliance.

Qualifications

• Requires university degree and 6–8 years of relevant experience (or education substitution).
• Current unrestricted RN license in the state you reside.
• Minimum five years of acute care clinical experience in a hospital setting.
• Experience in clinical denials, utilization review, case management, or appeals.
• Proficiency with InterQual, Milliman Care Guidelines, and EMR systems.

Responsabilités

• Conduct pre- and post-service medical necessity reviews for inpatient, observation, and outpatient hospital encounters using evidence-based criteria.
• 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.

Connaissances

Analytical

Organizational

Written communication

Independent case management

Multitasking

Formation

BSN

MSN

Outils

EMR systems

Description du poste

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.

What You Will Need:

Requires a University Degree and minimum 6-8 years of prior relevant experience; (Relevant experience may be substituted for formal education or advanced degree) Current unrestricted Registered Nurse license in the state you reside. 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. Proficiency with InterQual, Milliman Care Guidelines, and electronic medical record systems.

What Would Be Nice To Have:

Bachelor of Science in master’s degree in nursing Experience with inpatient level‑of‑care denials, DRG downgrades, and CMS payer rules. Active Compact License Strong working knowledge of hospital revenue cycle workflows, medical necessity review, and payer regulations.

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:

• 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.

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