Job description
SummaCare is a Summa Health entity that offers health insurance in northern Ohio. As a regional, provider-owned health plan, SummaCare is based in Akron, Ohio, and 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 5 out of 5-Star rating. SummaCare has also been recognized by U.S. News & World Report as being a Best Insurance Company for 2022 Medicare Advantage Plans. 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.
Reviews, processes, submits, and tracks all types including 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. Two (2) years performing claims processing or member services experience in a managed care environment
Other Skills, Competencies and Qualifications:
a. Demonstrate and maintain current understanding of various benefit packages, including intermediate knowledge of claims processes and systems.
b. Demonstrate intermediate knowledge of Microsoft Office applications requirements to complete job functions (e.g. Word and Excel).
c. Demonstrates ability to practice knowledge of health insurance industry, including governing rules and regulations.
d. Demonstrates ability to maintain current knowledge of and comply with regulatory and company policies & procedures.
e. Demonstrates intermediate system knowledge; familiarity with telephone logs for research and logging purposes essential.
f. 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.
g. Communicate and work effectively with others through written and verbal means.
h. Ability to apply appropriate rules of grammar, usage, and style when preparing correspondence and documentation.
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.
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