Guidehouse Registered Nurse - Clinical Appeals in Helena, Montana
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 Clinical Appeals Registered Nurse will be directly responsible for reviewing denials & auditing client facility Medical Records (MR’s) for a variety of facility required reviews including but not limited to documentation integrity reviews, lost charge audits &/or denial appeals. Responsible for writing clinical denials based off medical necessity citing state statues, evidence based criteria, Interqual and MCG. This position will perform all related job duties as assigned. This position is 100% remote.
Essential Job Functions:
• Medical Records Review• Ensure documentation integrity• Construct warranted appeals• Coordinate pre-service authorization approvals
Duties and Responsibilities:
• Clinical review and intervention of accounts either prior to Date of Service or continuation of appeal and outcome/resolution.• Monitoring of new referrals and coordination• Conduct comprehensive Denial Root-cause analysis.• Perform a comprehensive/retrospective medical record reviews and documentations are present to support the services rendered and complete a warranted appeal.• Identify process gaps, and trends.• Utilize Evidence -based clinical guideline tool (Milliman ® or InterQual ®)• Research and application of regulatory policies to support clinical appeal.• Telephonic communication with payors or facility staff as necessary for account denial resolution.• Maintain current knowledge of basic Coding Clinic Guidelines.• Assist on training new hires and developing process tools.• Assist on process management and collaboration across internal and external stakeholders.• Ability to compile a working spreadsheet, performance reports and conduct oral presentations for both internal and external stakeholders.
• Current Registered Nurse licensure.• Minimum of 5 years clinical experience.• Clinical Denials Experience required.
• Utilization Review experience highly preferred.• Attention to detail, strong organizational skills and self-motivated.• Ability to independently & accurately make decisions and assimilate multiple data sources or issues related to problem solving.• 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.
The pay range for this position is $70,000-$80,000 and may vary based on location and experience.
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