Guidehouse Clinical Denials/Appeals Nurse - Remote in Albany, New York
Guidehouse is a leading global provider of consulting services to the public sector and commercial markets, with broad capabilities in management, technology, and risk consulting. By combining our public and private sector expertise, we help clients address their most complex challenges and navigate significant regulatory pressures focusing on transformational change, business resiliency, and technology-driven innovation. Across a range of advisory, consulting, outsourcing, and digital services, we create scalable, innovative solutions that help our clients outwit complexity and position them for future growth and success. The company has more than 12,000 professionals in over 50 locations globally. Guidehouse is a Veritas Capital portfolio company, led by seasoned professionals with proven and diverse expertise in traditional and emerging technologies, markets, and agenda-setting issues driving national and global economies. For more information, please visit www.guidehouse.com.
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. This position is 100% remote.
Essential Job Functions:
Medical Necessity ReviewsEnsure documentation integrityConstruct warranted appealsCoordinate 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 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 leadership
• Current Registered Nursing License.• Minimum of 5 years clinical experience.• Utilization Review experience a plus• Clinical Denials Experience required• 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.
The successful candidate must not be subject to employment restrictions from a former employer (such as a non-compete) that would prevent the candidate from performing the job responsibilities as described.
Candidates from Eastern Standard Time, Central Standard Time, and Pacific Standard Time Zones as well as candidates from Arizona, New Mexico and Utah will be considered for this position.
Guidehouse is an Equal Employment Opportunity / Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, citizenship status, military status, protected veteran status, religion, creed, physical or mental disability, medical condition, marital status, sex, sexual orientation, gender, gender identity or expression, age, genetic information, 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.
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.
Rewards and Benefits
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 Insurance
Personal and Family Sick Time & Company Paid Holidays
Position may be eligible for a discretionary variable incentive bonus
Parental Leave and Adoption Assistance
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
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