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
- Current Registered Nursing License
- 4+ years of experience in utilization management
- 3+ years of NICU, Peds experience
- 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
- Bachelor's degree in nursing
- Connecticut RN License highly preferred - or willing to obtain.
The annual salary range for this position is $74,000.00-$124,000.00. 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.
Benefits include:
- 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 GuidehouseGuidehouse is an Equal Opportunity Employer-Protected 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.
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.
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. Note that Guidehouse will never charge a fee or require a money transfer at any stage of the recruitment process and does not collect fees from educational institutions for participation in a recruitment event. Never provide your banking information to a third party purporting to need that information to proceed in the hiring process.
If any person or organization demands money related to a job opportunity with Guidehouse, please report the matter to Guidehouse's Ethics Hotline. If you want to check the validity of correspondence you have received, please contact recruiting@guidehouse.com. Guidehouse is not responsible for losses incurred (monetary or otherwise) from an applicant's dealings with unauthorized third parties.
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.
