Guidehouse
2 days ago
Job Family:
Clinical Appeals Nurse
Travel Required:
Clearance Required:
What You Will Do:
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.
Essential Job Functions:
Medical Necessity Reviews
Ensure documentation integrity
Construct warranted appeals
Coordinate pre-service authorization approvals
Duties and Responsibilities:
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 updates 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
What You Will Need:
Requires a Bachelor’s Degree (Relevant experience may be substituted for formal education or advanced degree).
Current Registered Nursing License.
Minimum 4-6 years of prior clinical experience
What Would Be Nice To Have:
Utilization Review experience a plus
## Indeedsponsored
## LI-Remote
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
About Guidehouse
Guidehouse is an Equal Opportunity Employer–Protected Veterans, Individuals with Disabilities or any other basis protected by law, ordinance, or regulation.
Guidehouse will consider for employment qualified applicants with criminal histories in a manner consistent with the requirements of applicable law or ordinance including the Fair Chance Ordinance of Los Angeles and San Francisco.
If you have visited our website for information about employment opportunities, or to apply for a position, and you require an accommodation, please contact Guidehouse Recruiting at 1-571-633-1711 or via email at RecruitingAccommodation@guidehouse.com. All information you provide will be kept confidential and will be used only to the extent required to provide needed reasonable accommodation.
All communication regarding recruitment for a Guidehouse position will be sent from Guidehouse email domains including @guidehouse.com or guidehouse@myworkday.com. Correspondence received by an applicant from any other domain should be considered unauthorized and will not be honored by Guidehouse. Note that Guidehouse will never charge a fee or require a money transfer at any stage of the recruitment process and does not collect fees from educational institutions for participation in a recruitment event. Never provide your banking information to a third party purporting to need that information to proceed in the hiring process.
If any person or organization demands money related to a job opportunity with Guidehouse, please report the matter to Guidehouse’s Ethics Hotline. If you want to check the validity of correspondence you have received, please contact recruiting@guidehouse.com. Guidehouse is not responsible for losses incurred (monetary or otherwise) from an applicant’s dealings with unauthorized third parties.
Guidehouse does not accept unsolicited resumes through or from search firms or staffing agencies. All unsolicited resumes will be considered the property of Guidehouse and Guidehouse will not be obligated to pay a placement fee.