Job description
Job Family:
Clinical Appeals Nurse
Travel Required:
None
Clearance Required:
None
Responsibilities
- • 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.
• Excellent analytical, organizational, and written communication skills with the ability to independently manage multiple cases.
• Strong working knowledge of hospital revenue cycle workflows, medical necessity review, and payer regulations..
Requirements
- • Current unrestricted Registered Nurse license in the state you reside. (Compact license preferred)
• Minimum of five years of acute care clinical experience in a hospital setting.
• Prior experience in clinical denials, utilization review, case management, or appeals required.
What Would Be Nice To Have:
• Bachelor of Science in Nursing required; master’s degree in nursing
• Experience with inpatient level‑of‑care denials, DRG downgrades, and CMS payer rules
• Proficiency with InterQual, Milliman Care Guidelines, and electronic medical record systems
The annual salary range for this position is $68,000.00-$113,000.00. 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.
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
