Guidehouse (via agency) · Healthcare · Live in: United States
Posted 2026-11-06 · Verified 2026-11-06
Job Family : Clinical Appeals Nurse Travel Required : None Clearance Required : None What You Will Do : Conduct pre‑ and post‑service medical necessity reviews for inpatient, observation, and outpatient hospital encounters using evidence‑based criteria such as InterQual and Milliman Care Guidelines. Perform retrospective medical record reviews to validate completeness and accuracy of physician and clinical documentation supporting level of care and services rendered. Identify denial root causes and determine appeal viability based on payer policies, regulatory guidance, and clinical standards. Prepare, submit, and track clinical appeals, including written appeals. Collaborate with Patient... Read the full ad