Denial and Appeals Management Clerk

Overview

Location:

San Manuel - Grand Terrace, CA 92313
Position Type:
Full Time
Education Level: HS Diploma & License/Certification
Salary Range: $22.00 - $23.00 Hourly
Travel:
None

Job Shift: Day with Weekends as Needed
Job Category: HIM, Billing, and Coding

To be considered for this position, applicants must submit a fully completed application by the posted deadline.

The Denials and Appeals Management Clerk reviews, researches, resolves, and appeals denied or underpaid claims to maximise reimbursement and reduce accounts receivable delays. This role works with third‑party payers, billing, coding, credentialing, providers, and internal departments to ensure timely payment, accurate claim submission, and compliance with applicable regulations. It analyzes denial trends, identifies payer issues, supports process improvement, and helps prevent future denials.

This position may have a hybrid work schedule.

• Review and prioritize high-dollar and timely filing–sensitive denied claims from mail, clearinghouses, payer portals, and work queues.
• Analyze denied claims, reason codes, and determine appropriate corrective actions.
• Identify root causes related to coding, insurance eligibility, referral, authorization, provider documentation, or billing errors.
• Correct claims and resubmit within payer filing limits.
• Monitor aged, denied claims and maintain denial work queues.
• Document all actions and follow-up activities in the practice management system.
• Stay current on changes to payer policies, billing regulations, and reimbursement guidelines.
• Adhere to patient privacy and confidentiality requirements, including HIPAA regulations.
• Prepare and submit first-level and second-level appeals as appropriate.
• Gather supporting medical records, referrals, authorizations, and documentation.
• Draft appeal letters citing payer policies, medical necessity, coding guidelines, and regulatory requirements.
• Track appeal status through payer portals, calls, and deadlines until resolution.
• Escalate unresolved claims to management or payer representatives as appropriate.
• Coordinate peer-to-peer reviews and reconsideration requests when necessary.
• Identify denial trends by payer and denial reason and recurring issues.
• Assist in denial prevention education and implement corrective action plans.
• Collaborate with coding, billing, patient registration, medical records, and providers to prevent future denials.
• Maintain denial logs and appeal tracking spreadsheets.
• Support quality assurance and internal audits.
• Participate in revenue cycle meetings and payer issue resolution.
• Monitor denial rates and appeal outcomes.
• Assist in preparing monthly reports that include denial volume, top denial categories, appeal success rates, timely filing issues, and underpayment trends.
• This position requires working weekends and evenings, if needed.
• Other duties assigned relevant to the position, with training and competency assessment documented.

• Education: High School Diploma or Equivalent required. Associate degree in healthcare administration or finance preferred.
• Certification: Certified Professional Biller (CPB) required.
• Experience: Minimum two years in healthcare revenue cycle, medical billing, claims processing, collections, and denial management. Experience with Medicare, Medi-Cal, Managed Care, and Commercial Insurance payers required. Experience in an FQHC, Tribal Health, or community health center preferred.
• Knowledge: Medical terminology, CPT, HCPCS, ICD-10-CM coding concepts; claim adjudication; EOBs; ERAs; payer portals; denial and appeals management; timely filing limits; and appeal processes. Proficiency with EHR/Practice Management systems (Next Gen preferred) and clearinghouses such as Waystar preferred. Knowledge of healthcare regulations, coding standards, and payer requirements related to denials and appeals.
• Skills: Strong analytical, organizational, and problem-solving abilities; excellent verbal and written communication; proficiency with Microsoft Office. Willingness to complete Native American cultural competency training as needed.
• Ability: Interpret claim denials, review documentation, and develop effective appeal strategies. Investigate denials, identify root causes, and implement corrective actions. Prioritize workload and meet productivity goals while maintaining confidentiality and HIPAA compliance. Must be able to work with the Indian Community and be sensitive to its needs.

Prolonged sitting and computer use; occasional lifting of 20–25 pounds; dexterity for computer tasks and manual handling as needed.

Hybrid work schedule may be eligible subject to supervisor approval and organizational needs.

Full-Time, Non-Exempt

$22.00–$23.00 per hour ($45,760–$47,840 annually, depending on experience and internal equity)

San Manuel Indian Health Clinic (11980 Mt. Vernon Ave., Grand Terrace, CA 92313)