Clinical Denial/Appeals RN

Clinical Appeals Nurse

The Clinical Denials RN is responsible for review, analysis and appeal of clinical denials from insurance companies and third-party payers. This role requires a strong clinical background, knowledge of medical necessity criteria, and expertise in appealing denied claims. Essential Job Functions:

• Medical Necessity Reviews
• Ensure documentation integrity
• Construct warranted appeals
• Coordinate pre-service authorization approvals

Duties and Responsibilities:

• Conduct comprehensive Denial Root-cause analysis
• CV DRG Reviews
• Medical/Legal Reviews
• 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
• 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:

• Bachelor's Degree (Relevant experience may be substituted for formal education or advanced degree)
• Current Registered Nursing License
• 4+ years of prior clinical experience
• 1+ years of experience in post claim clinical appeals

What Would Be Nice To Have:

• Legal Nurse Consultant Certification
• Cerner/Epic Superuser
• Nurse Auditor Experience
• CV/DRG Appeal Experience
• Medical/Legal Nursing Experience

The annual salary range for this position is $81,000.00-$135,000.00. 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.

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.

All communication regarding recruitment for a Guidehouse position will be sent from Guidehouse email domains including @guidehouse.com or guidehouse@myworkday.com. Correspondence received by an applicant from any other domain should be considered unauthorized and will not be honored by Guidehouse. Guidehouse will never charge a fee or require a money transfer at any stage of the recruitment process.