Clinical Appeals NurseThe 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 :Review denials based on CARC code to determine root causeEnsure documentation integrityConstruct warranted appealsCoordinate pre-service authorization approvalsDuties 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 CycleUtilize 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 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 & 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.What You Will Need :Current Registered Nursing LicenseBachelor's Degree (Relevant experience may be substituted for formal education or advanced degree)4years of clinical experienceWhat Would Be Nice To Have :Utilization management experienceThe annual salary range for this position is $74,000.00-$124,000.00.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.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 Guidehouse :Guidehouse is an Equal Opportunity EmployerProtected 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.. Experience: 3 years required