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About the Role

This role focuses on managing and resolving denied hospital claims, requiring root cause analysis and coordination with various teams to ensure timely adjudication and process improvement.

Responsibilities

• 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 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/um 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.

Requirements

• Requires a high school diploma.
• 3-5 years of prior relevant experience in hospital revenue cycle, clinical denials, appeals, utilization management, or medical claims processing, health information management, or a related field.

Skills

• Organizational skills
• Analytical skills
• Written communication skills
• Ability to manage multiple accounts simultaneously
• Ability to meet strict deadlines

Location

• None

Work Type

• None

Experience Level

• 3-5 years

Education Level

• High school diploma
• Associates or Bachelors in healthcare administration
• Clinical background

Salary/Compensations

• $49,000.00-$81,000.00

Benefits

• 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 the Company

• Guidehouse is a global AI-led professional services firm delivering advisory, technology, and managed services to the commercial and government sectors.
• With an integrated business technology approach, Guidehouse drives efficiency and resilience in the healthcare, financial services, energy, infrastructure, and national security markets.
• Built to help clients across industries outwit complexity, the firm brings together approximately 18,000 professionals to achieve lasting impact and shape a meaningful future.
• guidehouse.com

Equal Opportunity

• 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.