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Registered Nurse – Clinical Denials/Appeals – Remote, Any Location
US - Remote (Any location) 31013 Job Family: Clinical Appeals Nurse Travel Required: None Clearance Required: None What You Will Do: The Remote Clinical Denials RN is responsible for review, analysis and appeal of clinical denials from insurance companies and third-party payers. This role requires a strong clinical background, knowledge of medical necessity criteria, and expertise in appealing denied claims. Essential Job Functions:
- Medical Necessity Reviews
- 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
- 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
- Bachelor’s Degree (Relevant experience may be substituted for formal education or advanced degree)
- Current Registered Nursing License
- 4+ years of prior clinical experience
- 1+ years of experience in post claim clinical appeals
- Acute care experience
- Bachelor's in nursing
- 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
