Clinical Denials & Appeals Nurse

US104 Guidehouse Managed Services LLC; Birmingham (AL); Hybrid; USD 68,000 - 113,000; Full time

Job summary

Guidehouse is seeking a Clinical Appeals Nurse to 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. This role emphasizes accuracy in documentation and collaboration across Revenue Cycle teams.

The ideal candidate holds a current RN license, at least five years of acute care experience, and prior denials/appeals work.

Qualifications

• 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.
• Bachelor of Science in Nursing required; master’s degree in nursing desirable.

Responsibilities

• Conduct pre‑ and post‑service medical necessity reviews for inpatient, observation, and outpatient hospital encounters.
• Perform retrospective medical record reviews to validate completeness and accuracy of physician and clinical documentation.
• Identify denial root causes and determine appeal viability based on payer policies, regulatory guidance, and clinical standards.
• Prepare, submit, and track clinical 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.

Skills

Analytical skills

Written communication

Organizational skills

Payer regulations knowledge

Clinical denials experience

Education

Bachelor of Science in Nursing

Tools

EMR systems

InterQual/Milliman guidelines

Job description

Guidehouse is seeking a Clinical Appeals Nurse to 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. This role emphasizes accuracy in documentation and collaboration across Revenue Cycle teams.

The ideal candidate holds a current RN license, at least five years of acute care experience, and prior denials/appeals work.