Guidehouse
Clinical Appeals Nurse
Job Family: Clinical Appeals Nurse Travel Required: None Clearance Required: None What You Will Do: Performs chart review of identified patients to identify quality, timeliness, and appropriateness of patient care Conducts admission reviews for Medicare, Medicaid beneficiaries, as well as private insurers and self-pay patients, based on appropriate guidelines Uses these criteria guidelines to screen for appropriateness for inpatient level of care or observation services based on physician certification Gathers clinical information to conduct continued stay utilization review activities with payers on a daily basis Performs concurrent and retrospective clinical reviews with various payers, utilizing the appropriate guidelines as demonstrated by compliance with all applicable regulations, policies, and timelines Adheres to CMS guidelines for utilization reviews as evidenced by utilization of the relevant guidelines and appropriate referrals to the physician advisor and the UR Committee Identifies, develops, and implements strategies to reduce length of stay and resource consumption. What You Will Need: Associate's degree minimum in nursing from an accredited school of nursing. New York Nursing License - REQUIRED 4+ years of experience in utilization management Familiarity with MCG and InterQual guidelines Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form What Would Be Nice To Have: Behavioral Health Experience Skilled Nursing Facility experience Inpatient Rehab Experience Bachelor's degree in nursing The annual salary range for this position is $81,000.00-$135,000.00. Compensation decisions depend on a wide range of factors, including but not limited to skill sets, experience and training, security clearances, licensure and certifications, and other business and organizational needs. What We Offer: 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. 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 About Guidehouse: Guidehouse is an Equal Opportunity EmployerProtected Veterans, Individuals with Disabilities 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. All communication regarding recruitment for a Guidehouse position will be sent from Guidehouse email domains including @guidehouse.com or
guidehouse@myworkday.com . Correspondence received by an applicant from any other domain should be considered unauthorized and will not be honored by Guidehouse. Guidehouse does not accept unsolicited resumes through or from search firms or staffing agencies.
Job Family: Clinical Appeals Nurse Travel Required: None Clearance Required: None What You Will Do: Performs chart review of identified patients to identify quality, timeliness, and appropriateness of patient care Conducts admission reviews for Medicare, Medicaid beneficiaries, as well as private insurers and self-pay patients, based on appropriate guidelines Uses these criteria guidelines to screen for appropriateness for inpatient level of care or observation services based on physician certification Gathers clinical information to conduct continued stay utilization review activities with payers on a daily basis Performs concurrent and retrospective clinical reviews with various payers, utilizing the appropriate guidelines as demonstrated by compliance with all applicable regulations, policies, and timelines Adheres to CMS guidelines for utilization reviews as evidenced by utilization of the relevant guidelines and appropriate referrals to the physician advisor and the UR Committee Identifies, develops, and implements strategies to reduce length of stay and resource consumption. What You Will Need: Associate's degree minimum in nursing from an accredited school of nursing. New York Nursing License - REQUIRED 4+ years of experience in utilization management Familiarity with MCG and InterQual guidelines Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form What Would Be Nice To Have: Behavioral Health Experience Skilled Nursing Facility experience Inpatient Rehab Experience Bachelor's degree in nursing The annual salary range for this position is $81,000.00-$135,000.00. Compensation decisions depend on a wide range of factors, including but not limited to skill sets, experience and training, security clearances, licensure and certifications, and other business and organizational needs. What We Offer: 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. 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 About Guidehouse: Guidehouse is an Equal Opportunity EmployerProtected Veterans, Individuals with Disabilities 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. All communication regarding recruitment for a Guidehouse position will be sent from Guidehouse email domains including @guidehouse.com or
guidehouse@myworkday.com . Correspondence received by an applicant from any other domain should be considered unauthorized and will not be honored by Guidehouse. Guidehouse does not accept unsolicited resumes through or from search firms or staffing agencies.