Guidehouse Clinical Appeals Nurse Lead in Columbia, South Carolina
Guidehouse is a leading management consulting firm serving the public and commercial markets. We guide our clients forward towards new futures that build trust in society and your professional skills along the journey. Join us at Guidehouse.
The Clinical Appeals Nurse Lead 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. This position will perform all related job duties as assigned.
Duties and Responsibilities
Conducts comprehensive Denial Root-cause analysis.
Performs a comprehensive/retrospective medical record reviews and documentations are present to support the services rendered and complete a warranted appeal.
Identifies process gaps, and trends.
Utilizes evidence -based clinical guideline tool (Milliman ® or InterQual ®)
Researches and utilizes application of regulatory policies to support clinical appeal.
Telephonic communication with payors or facility staff as necessary for account denial resolution.
Maintains current knowledge of basic Coding Clinic Guidelines.
Assists on training new hires and developing process tools
Assists on process management and collaboraton across internal and external stakeholders
Compiles a working spreadsheet, performance reports and conduct oral presentations for both internal and external stakeholders.
Collaborates with both internal/external stakeholders from VP to Manager level.
Current Registered Nurse licensure.
Minimum of 5 years RN clinical experience preferably in a hospital setting.
Experience working for a consulting firm and or health insurance.
Minimum 3 years of working experience in Utilization Management and/or hospital revenue cycle
Strong communication skills in both verbal and written.
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 leaders.
Personal responsibility, respect for self and others, innovation through teamwork, dedication to caring and excellence in customer service.
Deadline oriented assignments, heavy workload at times.
Experience in remote working location.
Up to 50% time spent working on computer & with Medical Records.
Up to 50% time on telephonic/webinar communication and or creating of workflow tools and report.
Essential Job Functions:
Medical records review
Construct warranted appeals
Project and process management
Documentation and change integrity
Research of applicable regulatory
Technical ability (Microsoft office tools)
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.
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.