Job Overview
Location
Indiana, USA
Job Type
Full-time
Category
Software Engineering
Date Posted
March 10, 2026
Full Job Description
đź“‹ Description
- • As a Clinical Denials RN at Guidehouse Inc., you will play a pivotal role in navigating the complex landscape of healthcare revenue cycle management, specifically focusing on the critical area of clinical denials and appeals.
- • Your primary responsibility will be to ensure that patient care is appropriately authorized and that any denials are meticulously reviewed and effectively appealed, thereby safeguarding the organization's financial health and ensuring patients receive the care they are entitled to.
- • This remote position offers the flexibility to work from anywhere in the US, providing a unique opportunity to contribute your expertise without the need for travel.
- • You will be instrumental in conducting thorough Medical Necessity Reviews, a cornerstone of the appeals process, ensuring that all treatments and services provided meet established clinical standards and are justifiable.
- • A key aspect of your role will involve ensuring the integrity of documentation, meticulously reviewing medical records to confirm that all necessary information is present and accurately reflects the patient's condition and the rationale for care.
- • You will be tasked with constructing well-reasoned and evidence-based appeals, presenting a compelling case to payers for the services rendered.
- • A significant part of your work will involve coordinating pre-service authorization approvals, proactively working to secure necessary permissions before care is delivered, thereby minimizing the risk of post-service denials.
- • You will perform comprehensive Denial Root-cause analysis, delving into the underlying reasons for claim denials to identify systemic issues and recommend improvements to prevent future occurrences.
- • Conducting retrospective medical record reviews will be essential to assure complete and accurate physician and staff documentation is present to support medical necessity, ensuring a robust foundation for appeals.
- • You will collaborate closely with hospital Patient Access and Mid-Revenue Cycle teams, fostering a coordinated approach to managing patient accounts and resolving issues efficiently.
- • A critical tool in your arsenal will be the utilization of evidence-based clinical guideline tools, such as Milliman® or InterQual®, to support your reviews and appeals, ensuring adherence to industry best practices.
- • You will research and apply regulatory policies relevant to healthcare claims and appeals, staying abreast of changes and ensuring compliance in all your actions.
- • Effective telephonic communication will be vital, as you will engage with payers, providers, hospital staff, and patients/families as necessary to bring accounts to resolution.
- • The role demands strong technical ability to multi-task across various systems, desktop applications, and Microsoft Office Suite while managing communication channels.
- • A working knowledge of basic Coding Guidelines will be beneficial in understanding claim submissions and denials.
- • You may be required to present oral presentations to client facilities or Guidehouse staff and leadership, articulating your findings and recommendations clearly and professionally.
- • Exceptional attention to detail, strong organizational skills, and a self-motivated work ethic are paramount for success in this role.
- • You must possess the ability to make sound decisions and assimilate multiple data sources or issues related to problem-solving independently and accurately.
- • Working under strict timelines and deadlines will be a regular occurrence, requiring you to provide clear and accurate updates to your project leader regarding assignment progress, hours worked, and expected outcomes on a daily basis.
- • Familiarity with medical records assembly and clinical terminology, along with coding terminology, will be highly beneficial in understanding the nuances of patient cases.
- • You will embody Guidehouse's core values, demonstrating personal responsibility, respect for self and others, innovation through teamwork, dedication to caring, and excellence in customer service in all your interactions.
- • This role is crucial in optimizing the revenue cycle, reducing claim denials, and improving the overall financial performance of the organization by ensuring that clinical documentation accurately supports the services provided and that appeals are handled with expertise and efficiency.
- • By proactively managing pre-service authorizations and effectively appealing post-service denials, you will contribute directly to the financial stability and operational efficiency of Guidehouse and its clients.
- • Your expertise as a Registered Nurse will be leveraged to bridge the gap between clinical care and administrative processes, ensuring that the financial aspects of healthcare delivery are managed with the same level of care and precision as patient treatment.
- • This position offers a significant opportunity for professional growth within a leading consulting firm, with ample resources for skills development and career advancement.
- • You will be part of a dynamic team dedicated to solving complex challenges in the healthcare industry, making a tangible impact on client outcomes and the broader healthcare ecosystem.
- • The remote nature of the role allows for a healthy work-life balance, enabling you to manage your professional responsibilities effectively while maintaining personal well-being.
- • Your contributions will be recognized and valued, as you become an integral part of a mission-driven organization committed to making a difference.
- • You will be empowered to take ownership of your work, utilizing your clinical judgment and analytical skills to achieve optimal results in a challenging yet rewarding environment.
- • The role provides exposure to a wide range of healthcare providers and payer systems, broadening your understanding of the industry and enhancing your professional network.
- • Ultimately, your success in this role will directly contribute to the financial integrity of healthcare organizations and the seamless delivery of patient care.
🎯 Requirements
- • Current Registered Nursing License
- • Bachelor’s Degree (Relevant experience may be substituted for formal education or advanced degree)
- • 4+ years of clinical experience
- • Utilization Review experience a plus
🏖️ Benefits
- • Medical, Rx, Dental & Vision Insurance
- • Personal and Family Sick Time & Company Paid Holidays
- • 401(k) Retirement Plan
Skills & Technologies
Remote
Degree Required
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.
