Summa Health
Appeals & Grievances Representative I
SummaCare – 1200 E Market St, Akron, OH (Full‑time, 40 hours)
Hybrid after training.
Summary Reviews, processes, submits, and tracks post‑service and non‑expedited appeals and grievances. Communicates to departments responsible for implementing determinations.
Formal Education Required
High School Diploma or equivalent
Experience & Training Required
One (1) year of relevant experience (appeals/grievances experience in a managed care environment, or claims processing/member services/patient care, or administrative support in any industry).
Essential Functions
Investigates and prepares post‑service, non‑expedited appeals and grievances within designated timeframes.
Researches member appeal/denial situations via phone interactions and written communications.
Participates in weekend on‑call rotation when required.
Prepares appeal/grievance files for review by Medical Directors, Appeals Coordinator, or Appeals Committee.
Writes acknowledgement and resolution letters to members, providers and other parties within defined timeframes and format. Processes logs and files consistently.
Communicates decisions to implementing departments and ensures proper implementation.
Communicates with members and providers while resolving appeals/grievances.
Assists in tracking appeal/grievance activity.
Prepares documents and records minutes of Appeals Committee meetings.
Performs all job functions with integrity, providing timely internal and external customer service in a cooperative, professional, respectful manner.
Other Skills, Competencies and Qualifications
Ability to learn and maintain current understanding of benefit packages, claims processes and systems.
Excellent written and verbal communication skills.
Strong grammar, usage, and style for correspondence.
Proficiency in Microsoft Office (Word, Excel).
Knowledge of health insurance industry, governing rules and regulations.
Compliance with regulatory and company policies & procedures.
Claims system knowledge; familiarity with telephone logs.
Identifies coding problems on authorization and claim screens.
Balanced professional demeanor with warm, customer‑first attitude.
Strong organizational and time‑management skills in fast‑paced environment.
Maintains confidentiality of patient and business information.
Flexibility to adjust work hours to meet business demands.
Level of Physical Demands
Sit and/or stand for prolonged periods.
Bend, stoop, and stretch.
Lift up to 20 pounds.
Manual dexterity to operate computer, phone, and standard office machines.
Salary $21.54/hr – $25.86/hr (base salary exclusive of bonuses or differentials. Salary range is full base salary.)
Benefits
Basic Life and Accidental Death & Dismemberment (AD&D)
Supplemental Life and AD&D
Dependent Life Insurance
Short‑Term and Long‑Term Disability
Accident Insurance, Hospital Indemnity, and Critical Illness
Retirement Savings Plan
Flexible Spending Accounts – Healthcare and Dependent Care
Employee Assistance Program (EAP)
Identity Theft Protection
Pet Insurance
Education Assistance
Daily Pay
Equal Opportunity Employer Equal Opportunity Employer. Veterans and individuals with disabilities encouraged to apply. Summa Health is an equal‑opportunity employer.
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Hybrid after training.
Summary Reviews, processes, submits, and tracks post‑service and non‑expedited appeals and grievances. Communicates to departments responsible for implementing determinations.
Formal Education Required
High School Diploma or equivalent
Experience & Training Required
One (1) year of relevant experience (appeals/grievances experience in a managed care environment, or claims processing/member services/patient care, or administrative support in any industry).
Essential Functions
Investigates and prepares post‑service, non‑expedited appeals and grievances within designated timeframes.
Researches member appeal/denial situations via phone interactions and written communications.
Participates in weekend on‑call rotation when required.
Prepares appeal/grievance files for review by Medical Directors, Appeals Coordinator, or Appeals Committee.
Writes acknowledgement and resolution letters to members, providers and other parties within defined timeframes and format. Processes logs and files consistently.
Communicates decisions to implementing departments and ensures proper implementation.
Communicates with members and providers while resolving appeals/grievances.
Assists in tracking appeal/grievance activity.
Prepares documents and records minutes of Appeals Committee meetings.
Performs all job functions with integrity, providing timely internal and external customer service in a cooperative, professional, respectful manner.
Other Skills, Competencies and Qualifications
Ability to learn and maintain current understanding of benefit packages, claims processes and systems.
Excellent written and verbal communication skills.
Strong grammar, usage, and style for correspondence.
Proficiency in Microsoft Office (Word, Excel).
Knowledge of health insurance industry, governing rules and regulations.
Compliance with regulatory and company policies & procedures.
Claims system knowledge; familiarity with telephone logs.
Identifies coding problems on authorization and claim screens.
Balanced professional demeanor with warm, customer‑first attitude.
Strong organizational and time‑management skills in fast‑paced environment.
Maintains confidentiality of patient and business information.
Flexibility to adjust work hours to meet business demands.
Level of Physical Demands
Sit and/or stand for prolonged periods.
Bend, stoop, and stretch.
Lift up to 20 pounds.
Manual dexterity to operate computer, phone, and standard office machines.
Salary $21.54/hr – $25.86/hr (base salary exclusive of bonuses or differentials. Salary range is full base salary.)
Benefits
Basic Life and Accidental Death & Dismemberment (AD&D)
Supplemental Life and AD&D
Dependent Life Insurance
Short‑Term and Long‑Term Disability
Accident Insurance, Hospital Indemnity, and Critical Illness
Retirement Savings Plan
Flexible Spending Accounts – Healthcare and Dependent Care
Employee Assistance Program (EAP)
Identity Theft Protection
Pet Insurance
Education Assistance
Daily Pay
Equal Opportunity Employer Equal Opportunity Employer. Veterans and individuals with disabilities encouraged to apply. Summa Health is an equal‑opportunity employer.
#J-18808-Ljbffr