Clinical Denials and Appeals RN - Remote

Guidehouse

Nov 13

Applications are closed

Job
Full-time
Mid & Senior Level
Legal
Healthcare
Washington
Remote

Requirements

Current Registered Nursing License.
Bachelor Degree or equivalent
Minimum of 4-6 years clinical experience
Clinical Denials Experience required

Responsibilities

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

FAQs

Is this position fully remote?

Yes, this position is a remote role.

What qualifications are required for the Clinical Denials and Appeals RN position?

A current Registered Nursing License and a Bachelor’s degree or equivalent are required, along with a minimum of 4-6 years of clinical experience and clinical denials experience.

Is there any travel required for this job?

No, travel is not required for this position.

What type of experience is preferred for applicants?

Utilization Review experience is a plus, but not required.

What are the key responsibilities of the Clinical Denials and Appeals RN?

Key responsibilities include conducting medical necessity reviews, coordinating pre-service authorization approvals, performing denial root-cause analysis, and collaborating with hospital staff and payors.

What tools will I be expected to use in this role?

You will utilize Evidence-based clinical guideline tools such as Milliman® or InterQual®, as well as various systems and Microsoft applications.

What are the typical working hours for this position?

The job description does not specify exact working hours, but it mentions the ability to work under deadlines and provide daily updates is important.

Are there any benefits included with this job?

Yes, the position offers a comprehensive benefits package, including medical, dental, vision insurance, paid sick time, parental leave, a 401(k) retirement plan, tuition reimbursement, and more.

What is the salary range for this position?

The annual salary range for this position is between $65,400.00 and $98,200.00, depending on various factors including skills and experience.

How does the company view diversity and inclusion?

Guidehouse is an Equal Employment Opportunity / Affirmative Action employer, committed to creating a diverse and supportive workplace.

What should I do if I need an accommodation during the application process?

If you require an accommodation, you can contact Guidehouse Recruiting at 1-571-633-1711 or email RecruitingAccommodation@guidehouse.com for assistance.

Guidehouse

Consulting

Industry

10,001+

Employees

2018

Founded Year

Mission & Purpose

Guidehouse is a leading global provider of consulting services to the public sector and commercial markets, with broad capabilities in management, technology, and risk consulting. By combining our public and private sector expertise, we help clients address their most complex challenges and navigate significant regulatory pressures focusing on transformational change, business resiliency, and technology-driven innovation. Across a range of advisory, consulting, outsourcing, and digital services, we create scalable, innovative solutions that help our clients outwit complexity and position them for future growth and success. The company has more than 12,000 professionals in over 50 locations globally. Guidehouse is a Veritas Capital portfolio company, led by seasoned professionals with proven and diverse expertise in traditional and emerging technologies, markets, and agenda-setting issues driving national and global economies.