Clinical Denial RN

Guidehouse; Washington (District of Columbia); On-site; USD 68,000 - 113,000; Full time

Benefits offered by this job

Medical insurance

401(k) plan

Paid holidays

Job summary

Guidehouse in Washington, DC is seeking a Clinical Appeals Nurse to conduct pre- and post-service medical necessity reviews for inpatient, observation, and outpatient hospital encounters. You will perform retrospective chart reviews to validate documentation supporting level of care and services rendered.

The role requires RN licensure, 5+ years of acute care hospital experience, and prior work in clinical denials or appeals.

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.
• Experience in clinical denials, utilization review, case management, or appeals.

Responsibilities

• Conduct pre- and post-service medical necessity reviews for inpatient, observation, and outpatient hospital encounters using evidence-based criteria.
• Perform retrospective medical record reviews to validate documentation supporting level of care and services rendered.
• Identify denial root causes and determine appeal viability based on payer policies 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.
• Research payer policies, CMS rules, and contractual language to support appeal arguments.
• Track denial outcomes, identify trends, and propose process improvements and staff education.

Skills

InterQual

Milliman Care Guidelines

Clinical denials

Utilization review

Case management

Written communication

Education

Bachelor of Science in nursing

Master’s degree in nursing

Tools

EMR systems

Job description

Job Family:Clinical Appeals NurseTravel Required:NoneClearance Required:NoneWhat 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 nursingExperience with inpatient level‑of‑care denials, DRG downgrades, and CMS payer rules.Active Compact LicenseStrong 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 InsurancePersonal and Family Sick Time & Company Paid HolidaysPosition may be eligible for a discretionary variable incentive bonusParental Leave401(k) Retirement PlanBasic Life & Supplemental LifeHealth Savings Account, Dental/Vision & Dependent Care Flexible Spending AccountsShort-Term & Long-Term DisabilityTuition Reimbursement, Personal Development & Learning OpportunitiesSkills Development & CertificationsEmployee Referral ProgramCorporate Sponsored Events & Community OutreachEmergency Back-Up Childcare ProgramAbout GuidehouseGuidehouse 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. Note that Guidehouse will never charge a fee or require a money transfer at any stage of the recruitment process and does not collect fees from educational institutions for participation in a recruitment event. Never provide your banking information to a third party purporting to need that information to proceed in the hiring process.If any person or organization demands money related to a job opportunity with Guidehouse, please report the matter to Guidehouse’s Ethics Hotline. If you want to check the validity of correspondence you have received, please contact [e-mail]. Guidehouse is not responsible for losses incurred (monetary or otherwise) from an applicant’s dealings with unauthorized third parties.Guidehouse does not accept unsolicited resumes through or from search firms or staffing agencies. All unsolicited resumes will be considered the property of Guidehouse and Guidehouse will not be obligated to pay a placement fee.