[Hiring] Clinical Denials/Appeals RN @Guidehouse

Role Description

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.

• Review denials based on CARC code to determine root cause
• 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 update 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.

Qualifications

• Current Registered Nursing License
• Bachelor’s Degree (Relevant experience may be substituted for formal education or advanced degree)
• 4+ years of clinical experience

Requirements

• Utilization management experience

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