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SummaCare



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APPEALS & GRIEVANCES REP


col-wide

Job Description:

SummaCare, Inc., a regional health insurance company based in Akron, Ohio, is looking for a representative to review, process, submit, and track post service and non-expedited appeals/grievances. The selected individual will communicate to departments responsible for implementing determinations.

Essential Functions and Responsibilities

  1. Investigates and prepares post service, non-expedited appeals/grievances appropriately and consistently, within designated timeframes.
  2. Researches customers appeal/denial situations submitted in both phone interactions and in written communications.
  3. Prepares post service, non-expedited appeals/grievances files for review by Medical Directors, Appeals Coordinator, or Appeals Committee.
  4. Writes post service, non-expedited appeal/grievance acknowledgement and resolution letters to members, providers, and other appealing parties within defined time-frames and format. Processes logs and files post service, non-expedited appeals and grievances in an organized and consistent manner.
  5. Communicates post service, non-expedited appeal/grievance decisions to departments responsible for implementing determinations; ensures decisions are implemented correctly.
  6. Communicates with members and providers while resolving appeals/grievances.
  7. Assists in tracking post service, non-expedited appeal/grievance activity.
  8. Prepares documents for and records minutes of Appeals Committee meetings.

Other Skills & Abilities

  1. Demonstrate and maintain current understanding of various benefit packages, including basic knowledge of claims processes and systems.
  2. Apply appropriate rules of grammar, usage, and style when preparing correspondence and documentation.

Educational Requirements

High School Diploma/GED or may substitute with 1 year of like experience.

Required Experience

1 year experience with the following: 1) appeals/grievance experience in a managed care environment, OR 2) claims processing or member services experience in a managed care environment, OR 3) administrative support in any industry.

SummaCare is proud to be a Tobacco-Free Company. Applicants who test positive for nicotine during pre-employment testing are not eligible for hire.