Clinical Appeals/Denials RN at US104 Guidehouse Managed Services LLC — Remote

Job Family:

Clinical Appeals Nurse Travel Required:

None Clearance Required:

None

What You Will Do:

• 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.
• Perform retrospective medical record reviews to validate completeness and accuracy of physician and clinical documentation supporting level of care and services rendered.
• 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.
• Maintain accurate documentation of all review activities in hospital and payer systems in accordance with compliance standards.

What You Will Need:

• Current unrestricted Registered Nurse license in the state you reside.
• Requires a University Degree and minimum 4-6 years of prior relevant experience in acute care clinical experience in hospital setting (Relevant experience may be substituted for formal education or advanced degree)
• Prior experience in clinical denials, utilization review, case management, or appeals required

What Would Be Nice To Have:

• Bachelor of Science in Nursing
• Master’s degree in Nursing
• Experience with InterQual and/or Milliman Care Guidelines, and electronic medical record systems.
• Compact State RN License
• Experience with inpatient level‐of‐care denials, DRG downgrades, and CMS payer rules.
• Strong knowledge of hospital revenue cycle workflows, medical necessity review, and payer regulations.
• Excellent analytical, organizational, and written communication skills with the ability to independently manage multiple cases.

The annual salary range for this position is $74,000.00-$124,000.00. Compensation decisions depend on a wide range of factors, including but not limited to skill sets, experience and training, security clearances, licensure and certifications, and other business and organizational needs. What We Offer:

Benefits include:

• Medical, Rx, Dental & Vision Insurance
• Personal and Family Sick Time & Company Paid Holidays
• Position may be eligible for a discretionary variable incentive bonus
• Parental Leave
• 401(k) Retirement Plan
• Basic Life & Supplemental Life
• Health Savings Account, Dental/Vision & Dependent Care Flexible Spending Accounts
• Short-Term & Long-Term Disability
• Tuition Reimbursement, Personal Development & Learning Opportunities
• Skills Development & Certifications
• Employee Referral Program
• Corporate Sponsored Events & Community Outreach
• Emergency Back-Up Childcare Program

About Guidehouse