Clinical Denials & Appeals RN - Acute Care Expert

Guidehouse; United States; Presencial; USD 68.000 - 113.000; Tempo integral

Benefícios oferecidos por esta vaga

Medical, Rx, Dental & Vision Insurance

Paid Holidays

401(k)

Tuition Reimbursement

Employee Referral Program

Career development & learning

Emergency Back-Up Childcare

Resumo da vaga

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.

Qualificações

• 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.

Responsabilidades

• 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.

Conhecimentos

Analytical skills

Organizational skills

Written communication

Independent case management

Formação

University degree

RN license (unrestricted)

Ferramentas

InterQual

Milliman Care Guidelines

EMR systems

Descrição da vaga

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.