Clinical Denials and Appeals RN

Job Family:Clinical Appeals NurseTravel Required:NoneClearance Required:NoneWhat 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 ReviewsEnsure documentation integrityConstruct warranted appealsCoordinate pre-service authorization approvalsDuties and Responsibilities:Conduct comprehensive Denial Root-cause analysisRetrospective Medical Record reviews to assure complete and accurate physician/staff documentation is present to support medical necessityCollaboration with hospital Patient Access and Mid-Revenue CycleUtilize Evidence -based clinical guideline tool (Milliman ® or InterQual ®)Research and application of regulatory policies to support clinical appealTelephonic 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 callsWorking knowledge of basic Coding GuidelinesMay be required to present oral presentations to client facility or Guidehouse staff and leadershipAttention to detail, strong organizational skills and self-motivated.Ability to make decisions and assimilate multiple data sources or issues related to problem solving independently & accuratelyAbility to work under a timeline/deadline & provide clear & accurate updates to project leader of assignment progress, hours worked & expected outcomes dailyFamiliarity with medical records assembly & clinical terminology, coding terminology additionally beneficialPersonal responsibility, respect for self and others, innovation through teamwork, dedication to caring and excellence in customer serviceWhat 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 experienceWhat Would Be Nice To Have:Utilization Review experience a plus#IndeedsponsoredThe annual salary range for this position is $68,000.00-$113,000.00. Compensation decisions depend on a wide range of factors, including but not limited to skill sets, experience and training, security clearances, licensure and certifications, and other business and organizational needs.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 InsurancePersonal and Family Sick Time & Company Paid HolidaysPosition may be eligible for a discretionary variable incentive bonusParental Leave401(k) Retirement PlanBasic Life & Supplemental LifeHealth Savings Account, Dental/Vision & Dependent Care Flexible Spending AccountsShort-Term & Long-Term DisabilityTuition Reimbursement, Personal Development & Learning OpportunitiesSkills Development & CertificationsEmployee Referral ProgramCorporate Sponsored Events & Community OutreachEmergency Back-Up Childcare ProgramAbout GuidehouseGuidehouse 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 [email protected]. 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 [email protected]. 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 [email protected]. 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.Originally posted on Himalayas

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