[Hiring] Clinical Denials and Appeals RN @Guidehouse

Role Description

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.

Qualifications

• 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.

Requirements

• Bachelor of Science in Nursing.
• Master’s degree in nursing.
• Compact State RN License.
• Experience with InterQual and/or Milliman Care Guidelines, and electronic medical record systems.
• Experience with inpatient level‑of‑care denials, DRG downgrades, and CMS payer rules.
• Strong knowledge of hospital revenue cycle workflows, medical necessity review, and payer regulations.
• Excellent analytical, organizational, and written communication skills with the ability to independently manage multiple cases.

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.