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Guidehouse

Solving big problems, building trust in society, and empowering our clients to shape the future.

Clinical Denial Specialist

Clinical ResearchClinical ResearchFull TimeRemoteMid LevelTeam 10,001+Since 2018H1B SponsorCompany SiteLinkedIn

Location

United States

Posted

79 days ago

Salary

$40K - $66K / year

Seniority

Mid Level

No structured requirement data.

Job Description

Clinical Denial Specialist

Guidehouse

Job Family: Medical Assistant Travel Required: None Clearance Required: None What You Will Do: - Receive, triage, and prioritize denied hospital claims based on timely filing requirements, financial impact, and payer response deadlines. - Conduct root cause analysis to identify clinical, documentation, authorization, or payer‑related reasons for denial. - Coordinate clinical denial cases with nurse reviewers, coding, utilization management, and revenue cycle teams to determine appeal viability. - Assemble and submit complete appeal packets, ensuring inclusion of appropriate clinical documentation and payer‑specific requirements. - Submit appeals via payer portals, secure fax, or mail, and confirm receipt to ensure timely adjudication. - Perform systematic appeal follow‑up at defined intervals until final claim resolution is achieved. - Track denial and appeal activity, maintaining accurate documentation within hospital and payer systems. - Identify denial trends and recurring issues and communicate findings to leadership to support process improvement initiatives. - Adhere to all hospital policies, payer guidelines, and regulatory requirements related to claims and appeals processing. What You Will Need: - Associate or bachelor’s degree in healthcare administration, medical assistant, health information management, or a related field. - Prior experience in hospital revenue cycle, clinical denials, appeals, utilization management, or medical claims processing. - Strong understanding of payer denial codes, appeal workflows, and hospital billing processes. What Would Be Nice To Have: - Clinical background or experience working directly with nursing or utilization management teams. - Experience with inpatient hospital claims, DRG‑based reimbursement, and payer portals. - Excellent organizational, analytical, and written communication skills. - Ability to manage multiple accounts simultaneously while meeting strict deadlines - Strong understanding of payer denial codes, appeal workflows, and hospital billing processes. #LI-DNI The annual salary range for this position is $40,000.00-$66,000.00. 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 Guidehouse Guidehouse 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.

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