Job Overview
Location
Indiana, USA
Job Type
Full-time
Category
Product Management
Date Posted
March 10, 2026
Full Job Description
đź“‹ Description
- • As a Clinical Denial Specialist at Guidehouse Inc., you will play a critical role in navigating the complex landscape of healthcare revenue cycle management, specifically focusing on the crucial areas of DRG Validation reviews and clinical denials.
- • Reporting directly to the RN Supervisor/Manager, your primary responsibility will be to meticulously analyze patient accounts and clinical documentation to identify and appeal denied claims, ensuring that the organization receives appropriate reimbursement for services rendered.
- • This position demands a highly organized and detail-oriented individual who can effectively manage a caseload of complex denial scenarios, requiring a proactive approach to problem-solving and a keen understanding of healthcare regulations and payer policies.
- • You will be instrumental in the DRG validation process, ensuring that the assigned diagnostic related groups accurately reflect the patient's condition and the services provided, which directly impacts reimbursement levels.
- • A significant part of your role will involve investigating the root causes of clinical denials, which can stem from various factors including insufficient documentation, medical necessity disputes, or incorrect coding.
- • You will be responsible for gathering all necessary supporting documentation, including medical records, physician's notes, lab results, and operative reports, to build a strong case for appeal.
- • This involves close collaboration with clinical staff, coders, and other revenue cycle professionals to obtain the information needed to overturn denials.
- • You will prepare and submit comprehensive appeal letters and supporting documentation to insurance payers, adhering to specific payer guidelines and timelines.
- • The ability to adapt to a constantly evolving healthcare environment, including changes in payer policies and regulatory requirements, is essential for success in this role.
- • You will be expected to stay abreast of industry best practices and regulatory updates that may impact denial management and DRG validation.
- • This role requires a collaborative spirit, as you will work closely with a team of professionals on a day-to-day basis, sharing insights and contributing to collective problem-solving efforts.
- • Your contributions will directly impact the financial health of the organization by minimizing revenue leakage and optimizing reimbursement rates.
- • You will assist with end-of-month reporting, which may involve creating and interpreting charts, graphs, and pivot charts to present findings and trends related to denials and DRG validation.
- • Proficiency in Electronic Health Record (EHR) systems and various insurance portals will be crucial for accessing patient information, submitting appeals, and tracking claim status.
- • You will leverage your Microsoft Office Suite skills, particularly Excel, for data analysis, report generation, and communication.
- • This role offers the opportunity to contribute to a leading consulting firm that supports government and commercial clients in solving complex challenges.
- • You will be part of a remote team, providing flexibility while maintaining a high level of productivity and collaboration.
- • The Clinical Denial Specialist is a vital link in the revenue cycle, ensuring that patient care is appropriately recognized and reimbursed, thereby supporting the organization's mission and financial stability.
- • You will be expected to maintain a high level of accuracy and efficiency in all tasks, from initial claim review to final appeal resolution.
- • This position requires a strong understanding of medical terminology, clinical pathways, and healthcare reimbursement methodologies.
- • By effectively managing clinical denials and ensuring accurate DRG assignment, you will directly contribute to improved cash flow and reduced accounts receivable days.
- • You will be a key player in identifying process improvement opportunities within the denial management workflow, suggesting and implementing solutions to prevent future denials.
- • Your analytical skills will be put to the test as you dissect complex denial reasons and develop targeted appeal strategies.
- • This role is ideal for an individual who thrives in a dynamic environment and is passionate about healthcare finance and patient advocacy.
- • You will be an integral part of a team dedicated to ensuring the financial integrity of healthcare services provided.
- • The ability to communicate effectively, both verbally and in writing, is paramount for interacting with payers, internal stakeholders, and potentially patients.
- • You will be responsible for maintaining organized and up-to-date records of all denial and appeal activities.
- • This position offers a unique opportunity to develop expertise in a specialized area of healthcare revenue cycle management.
- • Your work will directly influence the organization's ability to secure necessary funding for patient care and operational expenses.
- • You will be a critical resource for understanding and navigating the intricacies of payer denials and DRG validation processes.
- • The role requires a commitment to continuous learning and professional development in the ever-changing healthcare industry.
- • You will contribute to a positive and productive work environment through your dedication and collaborative efforts.
- • Ultimately, the Clinical Denial Specialist ensures that the organization's clinical services are accurately represented and appropriately compensated.
🎯 Requirements
- • High school diploma or equivalent.
- • Minimum of 3+ years of experience in healthcare administration, insurance verification, or medical billing.
- • Proficiency in Electronic Health Record (EHR) systems and insurance portals.
- • Experience with Microsoft Office Suite, including creating charts, graphs, and pivot charts.
- • Experience with Utilization Management (UM) or Clinical Denials in a hospital or payer setting is preferred.
- • Medical Assistant certification or experience is preferred.
🏖️ Benefits
- • Medical, Rx, Dental & Vision Insurance
- • Personal and Family Sick Time & Company Paid Holidays
- • 401(k) Retirement Plan
Skills & Technologies
Remote
About Guidehouse Inc.
Guidehouse Inc. is a global consulting and managed services provider formed in 2018 from the public sector practice of PwC. The company advises public and commercial clients on strategy, technology, risk management, and operations, focusing on energy, financial services, health, defense, and cybersecurity. With 18,000 professionals in over 60 offices worldwide, it delivers implementation support, managed services, and digital solutions to federal agencies, utilities, and Fortune 500 organizations. Guidehouse is majority-owned by Veritas Capital and partners with governments and businesses to address complex regulatory, operational, and innovation challenges.
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