<p>Appeals & Grievances Intake Rep</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>Creates and prepares grievance and appeal (G&A) files for investigation. Ensures Member and provider G&A communications are delivered on time, per CMS regulations, via written letter, email, telephone call and fax. Informs Members and Providers that call the Appeals and Grievance Department by relaying timeframes, Plan decisions and other information specific to the Plan's processing of Appeals and Grievance work.</p> <p>Formal Education Required:</p> <p>a. High School Diploma or equivalent.</p> <p>Experience & Training Required:</p> <p>a. Two (2) years increasingly responsible clerical/secretarial experience.</p> <p>b. Claims processing or Member / Customer Service / Patient Care experience in a healthcare environment preferred.</p> <p>Essential Functions:</p> <p>1) Logs, date stamps, tracks, and reports on activities related to medical record reviews, health risk assessments, and inquiries received from members and/or providers from mail, email, fax and phone.</p> <p>2) Runs reports and present cases to Complaint Triage Team (CTT) which is a multidisciplinary team made up of Compliance, Medical Management, Claims, Provider Services, Customer Service, Configuration, Eligibility and Appeals and Grievances.</p> <p>3) Validates appropriate representative documentation is on file and/or if request is required.</p> <p>4) Contacts provider offices, members, and other resources to obtain medical records, information needed to complete reviews, and other supporting documentation as outlined in the reconsideration guidelines.</p> <p>5) Receives incoming department phone calls, creates appropriate documentation within process director, scans documents and maintains accurate files, in accordance with company policy and procedure.</p> <p>6) Maintains and submits work schedule to manager.</p> <p>7) Reviews claims data to determine correct benefit determinations and/or identify if claims correctly paid.</p> <p>8) Works departmental Macess queues; reviews and resolves in a timely manner.</p> <p>9) 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. 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. Ability to learn and maintain current knowledge of and comply with regulatory and company policies & procedures.</p> <p>f. Represents SummaCare in a professional demeanor with warm, non-confrontational customer-first attitude. Project empathy, confidence, and service-oriented attitude.</p> <p>g. Ability to organize and manage time to accurately complete tasks within designated time frames in fast paced environment.</p> <p>h. Ability to maintain confidentiality of patient and business information.</p> <p>i. 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>$18.31/hr - $21.97/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>