Clinical Denial RN

Guidehouse; United States; On-site; USD 68,000 - 113,000; Full time

Benefits offered by this job

Medical, Rx, Dental & Vision Insurance

Paid Holidays

401(k)

Tuition Reimbursement

Employee Referral Program

Career development & learning

Emergency Back-Up Childcare

Job summary

Guidehouse is seeking a Clinical Appeals Nurse to perform pre- and post-service reviews, validate medical records, and support denial appeals. You will collaborate across departments to resolve denials and ensure compliant documentation.

Requires an RN license, a university degree, and 5+ years in acute care with prior denial/appeals experience. Applicants should be proficient with InterQual, Milliman guidelines, and EMR systems.

Qualifications

• Requires a University Degree and 6–8 years of relevant experience.
• Current unrestricted RN license in the state of residence.
• Minimum of five years of acute care clinical experience in a hospital setting.
• Prior experience in clinical denials, utilization review, case management, or appeals.
• Proficiency with InterQual, Milliman Care Guidelines, and EMR systems.

Responsibilities

• Conduct pre- and post-service medical necessity reviews using InterQual and Milliman Care Guidelines.
• Perform retrospective medical record reviews to validate documentation supporting level of care.
• Identify denial root causes and determine appeal viability based on policies.
• 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.
• Research payer policies, CMS regulations, and contractual language to support appeal arguments.
• Track and report denial and appeal outcomes and provide process-improvement recommendations.
• Maintain accurate documentation of all review activities in hospital and payer systems.
• Demonstrate excellent analytical, organizational, and written communication skills.

Skills

Analytical skills

Organizational skills

Written communication

Independent case management

Education

University degree

RN license (unrestricted)

Tools

InterQual

Milliman Care Guidelines

EMR systems

Job description

• 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.

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

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

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 our 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.