Clinical Denials/Appeals RN

Guidehouse•Bakersfield, CA

14d•$74,000 - $124,000•Remote

About The Position

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.

Requirements

Current Registered Nursing License
Bachelor’s Degree (Relevant experience may be substituted for formal education or advanced degree)
4+ years of clinical experience

Nice To Haves

Utilization management experience

Responsibilities

Review denials based on CARC code to determine root cause
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
Utilize 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
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.

Benefits

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