Clinical Denial RN

Guidehouse•Atlanta, GA

About The Position

The Clinical Denial RN conducts pre- and post-service medical necessity reviews for inpatient, observation, and outpatient hospital encounters using evidence-based criteria such as InterQual and Milliman Care Guidelines. The role performs retrospective medical record reviews to validate the completeness and accuracy of physician and clinical documentation supporting level of care and services rendered. The position identifies denial root causes, evaluates appeal viability based on payer policies, regulatory guidance, and clinical standards, and prepares, submits, and tracks clinical appeals, including written appeals. The RN collaborates with Patient Access, Case Management, Utilization Management, Coding, and Mid-Revenue Cycle teams to resolve denials and prevent recurrence. The role also researches payer-specific policies, CMS regulations, and contractual language; tracks and reports denial and appeal outcomes; recommends process improvements and staff education; and maintains accurate review documentation in hospital and payer systems in accordance with compliance standards. Guidehouse offers a comprehensive total rewards package that includes competitive compensation and flexible benefits intended to support a diverse and supportive workplace. Compensation decisions may depend on skills, experience, training, clearances, licensure, certifications, and business and organizational needs.

Requirements

A university degree and a minimum of 6–8 years of prior relevant experience; relevant experience may be substituted for formal education or an advanced degree.
Current unrestricted Registered Nurse license in the state of residence.
At least five years of acute care clinical experience in a hospital setting.
Prior experience in clinical denials, utilization review, case management, or appeals.
Proficiency with InterQual, Milliman Care Guidelines, and electronic medical record systems.
Excellent analytical, organizational, and written communication skills, with the ability to independently manage multiple cases.

Nice To Haves

Bachelor of Science in nursing or a master’s degree in nursing.
Experience with inpatient level-of-care denials, DRG downgrades, and CMS payer rules.
Active Compact License.
Strong working knowledge of hospital revenue cycle workflows, medical necessity review, and payer regulations.

Responsibilities

Conduct pre- and post-service medical necessity reviews for inpatient, observation, and outpatient hospital encounters using evidence-based criteria.
Perform retrospective medical record reviews to validate the completeness and accuracy of physician and clinical documentation supporting level of care and services rendered.
Identify denial root causes and determine appeal viability based on payer policies, regulatory guidance, and clinical standards.
Prepare, submit, and track clinical appeals, including written appeals.
Collaborate with Patient Access, Case Management, Utilization Management, Coding, and Mid-Revenue Cycle teams to resolve denials and prevent recurrence.
Research and apply payer-specific policies, CMS regulations, and contractual language to support appeal arguments.
Track and report denial and appeal outcomes, identify trends, and recommend process improvements and staff education.
Maintain accurate documentation of review activities in hospital and payer systems in accordance with compliance standards.