Clinical Denials & Appeals 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

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.