<p>Appeals & Grievances Rep I</p> <p>SummaCare - 1200 E Market St, Akron, OH</p> <p>Full-Time / 40 Hours / Days</p> <ul> <li>Hybrid after training </li></ul> <p>As a regional, provider-owned health plan, SummaCare values the relationship between the members and their doctors. SummaCare is a part of Summa Health, an integrated healthcare delivery system that includes Summa Health System hospitals, its community-based health centers, dedicated clinicians and SummaCare. Based in Akron, Ohio, SummaCare provides Medicare Advantage, individual and family and commercial insurance plans. SummaCare has one of the highest rated Medicare Advantage plans in the state of Ohio, with a 4.5 out of 5-Star rating for 2025 by the Centers for Medicare and Medicaid Services (CMS). Known for its excellent customer service and personalized attention to members, SummaCare is committed to building lasting relationships. Employees can expect competitive pay and benefits.</p> <p>Summary:</p> <p>Reviews, processes, submits, and tracks post service and non-expedited appeals/grievances. Communicates to departments responsible for implementing determinations.</p> <p>Formal Education Required:</p> <p>a. High School Diploma or equivalent</p> <p>Experience & Training Required:</p> <p>a. One (1) year experience. Relevant experience includes:</p> <p>i. Appeals /grievance experience in a managed care environment, OR</p> <p>ii. Claims processing, member services or patient care experience in a healthcare environment, OR</p> <p>iii. Administrative support in any industry.</p> <p>Essential Functions:</p> <p>1) Investigates and prepares post service, non-expedited appeals & grievances appropriately and consistently, within designated timeframes.</p> <p>2) Researches Member appeal/denial situations submitted in both phone interactions and in written communications</p> <p>3) May be required to participate in weekend on-call rotation depending upon assigned role (Commercial and Medicare Appeals Representatives)</p> <p>4) Prepares post service, non-expedited appeals/grievances files for review by Medical Directors, Appeals Coordinator, or Appeals Committee.</p> <p>5) Writes post service, non-expedited appeal/grievance acknowledgement and resolution letters to members, providers, and other appealing parties within defined time-frames and format. Processes logs and files post service, non-expedited appeals and grievances in an organized and consistent manner.</p> <p>6) Communicates post service, non-expedited appeal/grievance decisions to departments responsible for implementing determinations; ensures decisions are implemented correctly.</p> <p>7) Communicates with members and providers while resolving appeals/grievances.</p> <p>8) Assists in tracking post service, non-expedited appeal/grievance activity.</p> <p>9) Prepares documents for and records minutes of Appeals Committee meetings.</p> <p>10) Performs all job functions with integrity. Provides timely internal and external customer service in cooperative, professional, and respectful manner.</p> <p>Other Skills, Competencies and Qualifications:</p> <p>a. Demonstrate ability to learn and maintain current understanding of various benefit packages, including basic knowledge of claims processes and systems.</p> <p>b. Communicate effectively with others through written and verbal means.</p> <p>c. Ability to apply appropriate rules of grammar, usage, and style when preparing correspondence and documentation.</p> <p>d. Demonstrate proficiency in Microsoft Office applications requirements to complete job functions (e.g. Word and Excel).</p> <p>e. Demonstrates ability to practice knowledge of health insurance industry, including governing rules and regulations. .</p> <p>f. Demonstrates ability to maintain current knowledge of and comply with regulatory and company policies & procedures.</p> <p>g. Demonstrates claims system knowledge; familiarity with telephone logs for research and logging purposes essential.</p> <p>h. Demonstrates ability to identify system coding problems on authorization and claim screens preventing payment of claims so as to direct problems to the correct department.</p> <p>i. Ability to balance need for decisive, professional demeanor with warm, non-confrontational customer-first attitude. Project empathy, confidence, and service-oriented attitude.</p> <p>j. Ability to organize and manage time to accurately complete tasks within designated time frames in fast paced environment.</p> <p>k. Ability to maintain confidentiality of patient and business information.</p> <p>l. Flexible: ability to adjust work hours to meet business demands.</p> <p>Level of Physical Demands:</p> <p>a. Sit and/or stand for prolonged periods of time.</p> <p>b. Bend, stoop, and stretch.</p> <p>c. Lift up to 20 pounds.</p> <p>d. Manual dexterity to operate computer, phone, and standard office machines.</p> <p>Equal Opportunity Employer/Veterans/Disabled</p> <p>$21.54/hr - $25.86/hr</p> <p>The salary range on this job posting/advertising is base salary exclusive of any bonuses or differentials. Many factors, such as years of relevant experience and geographical location are considered when determining the starting rate of pay. We believe in the importance of pay equity and consider internal equity of our current team members when determining offers. Please keep in mind that the range that is listed is the full base salary range. Hiring at the maximum of the range would not be typical.</p> <p>Summa Health offers a competitive and comprehensive benefits program to include medical, dental, vision, life, paid time off as well as many other benefits.</p> <ul> <li>Basic Life and Accidental Death & Dismemberment (AD&D) </li><li>Supplemental Life and AD&D </li><li>Dependent Life Insurance </li><li>Short-Term and Long-Term Disability </li><li>Accident Insurance, Hospital Indemnity, and Critical Illness </li><li>Retirement Savings Plan </li><li>Flexible Spending Accounts - Healthcare and Dependent Care </li><li>Employee Assistance Program (EAP) </li><li>Identity Theft Protection </li><li>Pet Insurance </li><li>Education Assistance </li><li>Daily Pay </li></ul>