Job Family:
Clinical Appeals Nurse
Travel Required:
Clearance Required:
What You Will Do:
The Clinical Appeals/UM RN Supervisor is responsible for overseeing a team of Registered Nurses conducting clinical denials management, appeal reviews, and payer dispute resolution activities. This role provides operational leadership, clinical guidance, quality oversight, and performance management to ensure timely and effective appeal submissions that maximize reimbursement and reduce revenue loss. The supervisor serves as a subject matter expert in utilization management, medical necessity criteria, payer regulations, and denial prevention strategies while fostering a high-performing and engaged team culture.
Key Responsibilities
Leadership & Staff Management
• Supervise, mentor, and develop a team of Clinical Appeals and Denials RNs.
• Conduct regular coaching sessions, performance reviews, and professional development planning.
• Monitor productivity, quality, and compliance metrics to ensure achievement of departmental goals.
• Facilitate team meetings, training sessions, and ongoing education initiatives.
• Manage staffing assignments, workload balancing, PTO coverage, and scheduling needs.
Clinical Appeals Oversight
• Oversee the review and management of medical necessity, authorization, and clinical validation denials.
• Ensure timely preparation and submission of first-level, second-level, and external appeals.
• Guide staff in developing evidence-based appeal arguments utilizing clinical documentation, regulatory requirements, and nationally recognized guidelines such as InterQual and MCG.
• Review complex and high-dollar denials and provide escalation support as needed.
• Ensure all appeals meet payer-specific requirements and submission deadlines.
Denials Management & Revenue Protection
• Analyze denial trends and identify root causes impacting reimbursement.
• Collaborate with Revenue Cycle, Case Management, Utilization Review, CDI, HIM, and Operational Leadership to implement denial prevention strategies.
• Monitor recoveries, overturn rates, appeal success metrics, and financial outcomes.
• Develop action plans to address payer performance concerns and recurring denial patterns.
• Participate in client and leadership meetings to present denials performance and recommendations.
Quality & Compliance
• Ensure adherence to organizational policies, regulatory requirements, and payer guidelines.
• Perform quality audits of appeal submissions and provide feedback to staff.
• Maintain expertise in CMS regulations, Medicare and Medicaid requirements, commercial payer policies, and industry best practices.
• Support audit readiness and compliance initiatives.
Operational Excellence
• Identify and implement process improvements that enhance efficiency, quality, and financial outcomes.
• Assist in developing standard operating procedures, workflows, and training materials.
• Utilize data analytics and reporting tools to monitor team effectiveness and operational performance.
• Support implementation of new clients, programs, and denial management initiatives.
What You Will Need:
• Active Registered Nurse (RN) license in good standing.
• Minimum of 5 years of clinical nursing experience.
• Minimum of 3 years of experience in clinical appeals, denials management, utilization management, case management, or revenue cycle operations.
What Would Be Nice To Have:
• Certified Case Manager (CCM), Accredited Case Manager (ACM), or related certification preferred.
• Experience supporting multiple hospital clients or health systems.
• Knowledge of hospital revenue cycle operations, payer contracting, and reimbursement methodologies.
• Experience with Epic and other clinical documentation systems.
• Previous leadership, supervisory, or team lead experience preferred.
• Strong knowledge of InterQual, MCG, Medicare, Medicaid, and commercial payer guidelines.
• Experience with electronic health records and utilization management systems.
#LI-DNI
The annual salary range for this position is $77,000.00-$129,000.00. 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.