Clinical Denial Nurse

🔥 58 minutes ago

🇺🇸 United States – Remote

💵 $68k - $113k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

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Guidehouse

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 2018

🏥 Healthcare

🎖️ Defense

📦 Logistics

💰 Grant on 2023-02

Healthcare • Defense • Logistics

Guidehouse is a global consultancy offering advisory, digital, and managed services across commercial and public sectors. It is purpose-built to support industries such as national security, financial services, healthcare, energy, and infrastructure. Guidehouse collaborates with leaders to navigate complexity and drives transformational changes that impact the future. Their expertise spans data analytics, digital technologies, risk management, and more, with a strong emphasis on sustainability and innovation.

📋 Description

• Conduct pre- and post-service medical necessity reviews for inpatient, observation, and outpatient hospital encounters • Use evidence-based criteria such as InterQual and Milliman Care Guidelines • Perform retrospective medical record reviews to validate documentation supporting level of care and services rendered • Identify denial root causes and determine appeal viability • Prepare, submit, and track clinical appeals, including written appeals • Collaborate with Patient Access, Case Management, Utilization Management, Coding, and Mid-Revenue Cycle teams • Research and apply payer-specific policies, CMS regulations, and contractual language • Track and report denial and appeal outcomes, identify trends, and recommend process improvements and staff education • Maintain accurate documentation of review activities in hospital and payer systems

🎯 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 • Excellent analytical, organizational, and written communication skills • Ability to independently manage multiple cases • Strong working knowledge of hospital revenue cycle workflows, medical necessity review, and payer regulations • Bachelor of Science in Nursing required • Experience with inpatient level-of-care denials, DRG downgrades, and CMS payer rules • Proficiency with InterQual, Milliman Care Guidelines, and electronic medical record systems

🏖️ Benefits

• 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 • Flexible benefits package • Flexible work arrangements