Senior Clinical Denials & Appeals 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

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.