Clinical Denials/Appeals RN/Registered Nurse - Remote 2 in Benton, AL
Job Description
Clinical Appeals Nurse
The Remote Clinical Denials/Appeals Nurse will be directly responsible for securing pre-service approvals, and reviewing pre/post service denials, medical necessity review and completing appeals and/or coordinating peer to peer reviews as appropriate. This position will perform all related job duties as assigned.
Essential Job Functions:
• Review denials based on CARC code to determine root cause
• Ensure documentation integrity
• Construct warranted appeals
• Coordinate pre-service authorization approvals
Duties and Responsibilities:
Conduct comprehensive Denial Root-cause analysis.
Retrospective Medical Record reviews to assure complete and accurate physician/staff documentation is present to support medical necessity.
Collaboration with hospital Patient Access and Mid-Revenue Cycle
Utilize Evidence-based clinical guideline tool (Milliman or InterQual )
Research and application of regulatory policies to support clinical appeal.
Telephonic communication with payors, provider, hospital staff and patient/family as necessary to bring the account into resolution.
Technical ability to multi-task on various systems, desktop and Microsoft applications while managing inbound calls.
Working knowledge of basic Coding Guidelines.
May be required to present oral presentations to client facility or Guidehouse staff and leadership
Attention to detail, strong organizational skills and self-motivated.
Ability to make decisions and assimilate multiple data sources or issues related to problem solving independently & accurately.
Ability to work under a timeline/deadline & provide clear & accurate update to project leader of assignment progress, hours worked & expected outcomes daily.
Familiarity with medical records assembly & clinical terminology, coding terminology additionally beneficial.
Personal responsibility, respect for self and others, innovation through teamwork, dedication to caring and excellence in customer service.
What You Will Need:
• Current Registered Nursing License
• Bachelor's Degree (Relevant experience may be substituted for formal education or advanced degree)
• 4+ years of clinical experience
What Would Be Nice To Have:
• Utilization management experience
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:
Guidehouse offers a comprehensive, total rewards package that includes competitive compensation and a flexible benefits package that reflects our commitment to creating a diverse and supportive workplace.
• 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:
Guidehouse is an Equal Opportunity EmployerProtected Veterans, Individuals with Disabilities or any other basis protected by law, ordinance, or regulation.
Guidehouse will consider for employment qualified applicants with criminal histories in a manner consistent with the requirements of applicable law or ordinance including the Fair Chance Ordinance of Los Angeles and San Francisco.
The Remote Clinical Denials/Appeals Nurse will be directly responsible for securing pre-service approvals, and reviewing pre/post service denials, medical necessity review and completing appeals and/or coordinating peer to peer reviews as appropriate. This position will perform all related job duties as assigned.
Essential Job Functions:
• Review denials based on CARC code to determine root cause
• Ensure documentation integrity
• Construct warranted appeals
• Coordinate pre-service authorization approvals
Duties and Responsibilities:
Conduct comprehensive Denial Root-cause analysis.
Retrospective Medical Record reviews to assure complete and accurate physician/staff documentation is present to support medical necessity.
Collaboration with hospital Patient Access and Mid-Revenue Cycle
Utilize Evidence-based clinical guideline tool (Milliman or InterQual )
Research and application of regulatory policies to support clinical appeal.
Telephonic communication with payors, provider, hospital staff and patient/family as necessary to bring the account into resolution.
Technical ability to multi-task on various systems, desktop and Microsoft applications while managing inbound calls.
Working knowledge of basic Coding Guidelines.
May be required to present oral presentations to client facility or Guidehouse staff and leadership
Attention to detail, strong organizational skills and self-motivated.
Ability to make decisions and assimilate multiple data sources or issues related to problem solving independently & accurately.
Ability to work under a timeline/deadline & provide clear & accurate update to project leader of assignment progress, hours worked & expected outcomes daily.
Familiarity with medical records assembly & clinical terminology, coding terminology additionally beneficial.
Personal responsibility, respect for self and others, innovation through teamwork, dedication to caring and excellence in customer service.
What You Will Need:
• Current Registered Nursing License
• Bachelor's Degree (Relevant experience may be substituted for formal education or advanced degree)
• 4+ years of clinical experience
What Would Be Nice To Have:
• Utilization management experience
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:
Guidehouse offers a comprehensive, total rewards package that includes competitive compensation and a flexible benefits package that reflects our commitment to creating a diverse and supportive workplace.
• 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:
Guidehouse is an Equal Opportunity EmployerProtected Veterans, Individuals with Disabilities or any other basis protected by law, ordinance, or regulation.
Guidehouse will consider for employment qualified applicants with criminal histories in a manner consistent with the requirements of applicable law or ordinance including the Fair Chance Ordinance of Los Angeles and San Francisco.
Job Details
Employment Type
Full-time
Required License
RN (Registered Nurse)
Years of Experience
Intermediate
Work Setting
Telehealth
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About Guidehouse
Guidehouse is a leading global provider of consulting services with a focus on driving cross-market advancements. With expertise in management, technology, and risk consulting, Guidehouse serves both the public sector and commercial markets, helping clients navigate complex challenges and regulatory pressures. By offering a wide range of advisory, consulting, outsourcing, and digital services, Guidehouse delivers innovative solutions that position clients for growth and success. With over 16,000 professionals worldwide, Guidehouse is uniquely positioned to integrate commercial and public sector perspectives to address intricate problems and drive transformational change.