Appeals & Grievances Representative I

Appeals & Grievances Representative I Summa Health - 3.5 Akron, OH Job Details Full-time $21.54 - $25.86 an hour 1 day ago Benefits AD&D insurance Disability insurance Health insurance Dental insurance Flexible spending account Paid time off Employee assistance program Vision insurance Life insurance Retirement plan Pet insurance Qualifications Medical claims processing software High school diploma or GED Healthcare privacy protection Desktop applications Productivity software Grammar Experience Full Job Description SummaCare - 1200 E Market St, Akron, OH Full-Time / 40 Hours / Days Hybrid 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 2026 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.

Summary:

Reviews, processes, submits, and tracks post service and non-expedited appeals/grievances. Communicates to departments responsible for implementing determinations.

Formal Education Required :

a. High School Diploma or equivalent

Experience & Training Required :

a. One (1) year experience.

Relevant experience includes:

i. Appeals /grievance experience in a managed care environment, OR ii. Claims processing, member services or patient care experience in a healthcare environment, OR iii. Administrative support in any industry.

Other Skills, Competencies and Qualifications:

a. Demonstrate ability to learn and maintain current understanding of various benefit packages, including basic knowledge of claims processes and systems. b. Communicate effectively with others through written and verbal means. c. Ability to apply appropriate rules of grammar, usage, and style when preparing correspondence and documentation. d. Demonstrate proficiency in Microsoft Office applications requirements to complete job functions (e.g. Word and Excel). e. Demonstrates ability to practice knowledge of health insurance industry, including governing rules and regulations. . f. Demonstrates ability to maintain current knowledge of and comply with regulatory and company policies & procedures. g. Demonstrates claims system knowledge; familiarity with telephone logs for research and logging purposes essential. 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. i. Ability to balance need for decisive, professional demeanor with warm, non-confrontational customer-first attitude. Project empathy, confidence, and service-oriented attitude. j. Ability to organize and manage time to accurately complete tasks within designated time frames in fast paced environment. k. Ability to maintain confidentiality of patient and business information. l.

Flexible:

ability to adjust work hours to meet business demands.

Level of Physical Demands:

a. Sit and/or stand for prolonged periods of time. b. Bend, stoop, and stretch. c. Lift up to 20 pounds. d. Manual dexterity to operate computer, phone, and standard office machines. Equal Opportunity Employer/Veterans/Disabled $21.54/hr - $25.86/hr 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. Summa Health offers a competitive and comprehensive benefits program to include medical, dental, vision, life, paid time off as well as many other 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