Clinical Appeals/Denials RN

🕒 Julho 31

🇺🇸 Estados Unidos – Remoto (EUA)

💵 $74.000 - $124.000 / ano

⏰ Tempo Integral

🟡 Pleno

🟠 Sênior

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Guidehouse

SiteLinkedInTodas as Vagas

10.000+ funcionários

Fundada em 2018

🏥 Saúde

🎖️ Defesa

📦 Logística

💰 Grant em 2023-02

Healthcare • Defense • Logistics

A Guidehouse é uma consultoria global que oferece serviços de consultoria, digitais e gerenciados nos setores comercial e público. Ela é projetada para apoiar indústrias como segurança nacional, serviços financeiros, saúde, energia e infraestrutura. A Guidehouse colabora com líderes para navegar na complexidade e impulsionar mudanças transformacionais que impactam o futuro. Sua expertise abrange análise de dados, tecnologias digitais, gestão de riscos e mais, com forte ênfase em sustentabilidade e inovação.

Descrição

• 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.

🎯 Requisitos

• 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

🏖️ Benefícios

• 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