Senior Clinical Denials & Appeals RN

Guidehouse; Atlanta (GA); Hybrid; USD 68,000 - 113,000; Full time

Benefits offered by this job

Medical insurance

Dental & Vision Insurance

Paid Holidays

401(k) Retirement Plan

Tuition Reimbursement

Employee Referral Program

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 InterQual and Milliman criteria.

The role requires RN licensure and 6–8 years of acute care experience, with experience in denials, utilization review, or appeals; you will prepare and track appeals, collaborate across teams, and ensure documentation compliance.

Qualifications

• Requires university degree and 6–8 years of relevant experience (or education substitution).
• Current unrestricted RN license in the state you reside.
• Minimum five years of acute care clinical experience in a hospital setting.
• 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 for inpatient, observation, and outpatient hospital encounters using evidence-based criteria.
• 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.

Skills

Analytical

Organizational

Written communication

Independent case management

Multitasking

Education

BSN

MSN

Tools

EMR systems

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 InterQual and Milliman criteria.

The role requires RN licensure and 6–8 years of acute care experience, with experience in denials, utilization review, or appeals; you will prepare and track appeals, collaborate across teams, and ensure documentation compliance.