Denial and Appeals Management Clerk

RIVERSIDE SAN BERNARDINO COUNTY INDIAN HEALTH INC•Grand Terrace, CA

11h•$22 - $23•Hybrid

About The Position

The Denial and Appeals Management Clerk reviews, researches, resolves, and appeals denied or underpaid claims to maximize reimbursement and reduce accounts receivable delays. The role works with third-party payers, billing, coding, credentialing, providers, and internal departments to support timely payment, accurate claim submission, and regulatory compliance. It also analyzes denial trends, identifies payer issues, supports process improvements, and helps prevent future denials. The position requires sensitivity to the Indian community and its cultural needs. The role is based at the San Manuel Indian Health Clinic in Grand Terrace, California. Hybrid work may be available after the introductory period, subject to supervisor approval, position requirements, and organizational needs. The position is full-time and non-exempt, pays $22.00–$23.00 per hour ($45,760–$47,840 annually, depending on experience and internal equity), and may require working evenings and weekends as needed.

Requirements

High school diploma or equivalent.
Diploma in Medical Coding and Billing.
At least two years of experience in healthcare revenue cycle, medical billing, claims processing, collections, and denial management.
Experience with Medicare, Medi-Cal, Managed Care, and Commercial Insurance payers.
Certified Professional Biller (CPB) certification through AAPC at hire or within one year of employment; other recognized billing or coding certifications may be considered.
BLS Provider certification through the American Heart Association or American Red Cross; certification may be obtained before orientation or within 90 days of employment.
Knowledge of medical terminology, CPT, HCPCS, ICD-10-CM coding concepts, claim adjudication, EOBs, ERAs, payer portals, timely-filing limits, and appeal processes.
Knowledge of healthcare regulations, coding standards, and payer requirements relevant to claim denials and appeals.
Proficiency with electronic health records and practice management systems.
Strong analytical, organizational, and problem-solving skills.
Excellent verbal and written communication skills.
Proficiency with Microsoft Office applications.
Ability to interpret claim denials, review documentation, and develop effective appeal strategies; investigate root causes and implement corrective actions.
Ability to prioritize workload, meet productivity goals, maintain confidentiality, and ensure HIPAA compliance.
Must be able to work with the Indian community and be sensitive to its culture and needs; must understand or be willing to receive Native American cultural competency training and employ cultural awareness.
Physical ability to sit for prolonged periods, use a computer, keyboard, and standard office equipment, occasionally lift 20 to 25 pounds, and use hand dexterity with eye-hand coordination.

Nice To Haves

Associate degree in Healthcare Administration, Finance, or a related field.
Experience in an FQHC, Tribal Health, or community health center.
Familiarity with NextGen electronic health records or practice management systems.
Experience using clearinghouses such as Waystar.
Other recognized medical billing or coding certifications, such as CPC, CCS, or CCA, may be considered.

Responsibilities

Review and prioritize high-dollar and timely-filing-sensitive denied claims received through mail, clearinghouses, payer portals, and work queues.
Analyze denied claims and reason codes, determine corrective actions, and identify root causes such as coding, eligibility, referral, authorization, documentation, or billing errors.
Correct and resubmit claims within payer filing limits; monitor aged and denied claims and maintain work queues.
Document actions and follow-up activities in the practice management system.
Stay current on payer policies, billing regulations, and reimbursement guidelines, and comply with patient privacy requirements, including HIPAA.
Prepare and submit first- and second-level appeals, gather supporting records and documentation, and draft appeal letters citing payer policies, medical necessity, coding guidelines, and regulatory requirements.
Track appeals through payer portals and telephone calls, monitor response deadlines, escalate unresolved claims when appropriate, and coordinate peer-to-peer reviews and reconsideration requests.
Identify denial trends by payer and reason, maintain denial logs and appeal tracking spreadsheets, and assist with denial-prevention education and corrective action plans.
Collaborate with coding, billing, patient registration, medical records, and providers to prevent future denials.
Support quality assurance, internal audits, revenue-cycle meetings, and payer issue resolution.
Monitor denial rates and appeal outcomes and assist with monthly reports on denial volume, top denial categories, appeal success rates, timely-filing issues, and underpayment trends.
Perform other relevant duties as assigned, with relevant training and competency assessment documented.