United States onlyJob Family:
Clinical Appeals NurseTravel Required:
NoneClearance Required:
NoneWhat You Will Do:
Clinical Review & Medical Necessity
Conducts comprehensive medical necessity reviews using evidence‑based guidelines (Milliman or InterQual)
Performs initial, concurrent, and retrospective reviews to ensure accuracy and completeness of documentation supporting medical necessity.
Routes cases to Physician Advisors when clinical criteria are not met or potential quality issues are identified.
Care Coordination & Collaboration
Partners with care managers, social workers, pharmacists, and multidisciplinary care teams to support progression‑of‑care objectives.
Identifies barriers to discharge and initiates appropriate discharge planning interventions.
Documentation, Compliance & Quality
Ensures thorough, timely, and accurate documentation in accordance with regulatory, payer, and organizational standards.
Adheres to utilization management performance metrics, including call volume, case reviews, and turnaround times.
Applies strong critical‑thinking skills to evaluate complex clinical scenarios and synthesize multiple data sources into sound decisions.
Technical & Professional Competencies
Utilizes multiple systems, Microsoft Office applications, and clinical tools
Maintains objectivity and consistency in decision‑making, leveraging clinical facts and established guidelines.
Demonstrates knowledge of reimbursement methodologies, payer regulations, and managed care trends.
What You Will Need
Bachelor's Degree (Relevant experience may be substituted for formal education or advanced degree)
Registered Nurse (NY License preferred or willing to obtain upon hire)
4+ years Utilization Management experience
Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form
What Would Be Nice To Have
Behavioral Health Experience
Medical Terminology
Bachelor's degree in nursing
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.
