<p>Claims Processor</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>Accurately and efficiently handles claims in accordance with regulatory and contractual guidelines. Reviews claims related to coordination of benefits, medical coding, and authorization allocation while ensuring compliance with established policies. Applies cost-containment strategies in collaboration with vendor partners to minimize claim expenses while adhering to plan-specific processing rules. are essential for success in this position.</p> <ol> <li>Formal Education Required: </li></ol> <p>a. High School Diploma or equivalent</p> <ol start="2"> <li>Experience & Training Required: </li></ol> <p>a. One (1) year experience to include any combination of the following:</p> <p>i. Health insurance claims processing</p> <p>ii. Health claims data entry including Document Management Services (DMS)</p> <p>iii. Customer service experience in a managed care environment</p> <p>iv. Physician or hospital billing</p> <p>v. Patient accounts</p> <p>Essential Functions:</p> <ol> <li> <p>Requires close attention to detail with independent judgment, decision making and problem solving skills necessary to complete the task being performed</p> </li><li> <p>Organizes reference materials for easy access; manages time to accurately complete tasks within time frames in a fast paced environment</p> </li><li> <p>Processes all types of claims, promptly and accurately, as assigned via the document management system, and ensures self-funded service standards, prompt pay standards, and regulatory requirements are met.</p> </li><li> <p>Maintains a working knowledge of the claims processing system, imaging system, key-stroke emulation system, code editing application, claims processing policies & procedures, and unique benefits/processing rules for self-funded, Medicare, MEWA, Marketplace and fully-insured plans.</p> </li><li> <p>Escalates questions or concerns to their mentor for evaluation and potential referral to the Claims Management staff for action plan and resolution</p> </li><li> <p>Meets or exceeds claims production and quality standards as established/communicated by Claims Management staff</p> </li><li> <p>Coordinates information and resolves service forms and other assignments promptly, in accordance with experience/capabilities. Handles special projects within timeframes established/assigned by supervisor</p> </li><li> <p>Other Skills, Competencies and Qualifications:</p> </li></ol> <p>a. Strong independent judgment and decision-making skills</p> <p>b. MS-windows based computer environment</p> <p>c. Medical terminology, CPT, HCPCs and ICD-10 knowledge</p> <p>d. Familiar with professional (CMS1500) and institutional (UB-04) claim types</p> <ol start="4"> <li>Level of Physical Demands: </li></ol> <p>a. Sit for prolonged periods of time</p> <p>b. Bend, stop 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>$19.23/hr - $23.08/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>