Summa Health
Appeals & Grievances Representative II
SummaCare - 1200 E Market St, Akron, OH
Full-Time / 40 Hours / Days
Hybrid after training
As a regional, provider‑owned health plan, SummaCare values the relationship between the members and their doctors. SummaCare is 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, family, and commercial insurance plans. SummaCare has one of the highest rated Medicare Advantage plans in 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.
Summary Reviews, processes, submits, and tracks all types of appeals and grievances, including expedited appeals. Communicates to departments responsible for implementing determinations.
Formal Education Required
High School Diploma or equivalent
Experience & Training Required
One (1) year of experience. Relevant experience includes: appeals/grievance experience in a managed care environment, or
Two (2) years performing claims processing, member services, or patient care experience in a healthcare environment
Essential Functions
Investigates, prepares and files all types of appeals and grievances, including expedited appeals, within designated timeframes
Investigates and researches member appeal/denial situations submitted in both phone interactions and written communications
May be required to participate in weekend on‑call rotation depending on assigned role (Commercial and Medicare Appeals Representatives)
Prepares post‑service, expedited appeal/grievance files for review by Medical Directors, Appeals Coordinator, or Appeals Committee
Writes appeals/grievance resolution letters to members, providers, and other appealing parties within defined time‑frames and format
Processes logs and files appeals and grievances in an organized and consistent manner
Communicates appeal/grievance decisions to departments responsible for implementing determinations, ensuring correct implementation
Communicates with members and providers while resolving appeals/grievances
Assists in tracking and trending appeal/grievance activity
Prepares documents for and records minutes of Appeals Committee meetings
Assists Appeals Coordinator as needed
May assist with the training of new staff and/or mentoring of new staff
Performs all job functions with integrity, providing timely internal and external customer service in a cooperative, professional, and respectful manner
Other Skills, Competencies and Qualifications
Demonstrate and maintain current understanding of various benefit packages, including intermediate knowledge of claims processes and systems
Demonstrate intermediate knowledge of Microsoft Office applications required to complete job functions (e.g., Word and Excel)
Demonstrate ability to practice knowledge of health insurance industry, including governing rules and regulations
Demonstrate ability to maintain current knowledge of and comply with regulatory and company policies and procedures
Demonstrate intermediate system knowledge; familiarity with telephone logs for research and logging purposes essential
Demonstrate ability to identify system coding problems on authorization and claim screens preventing payment of claims to direct problems to the correct department
Communicate and work effectively with others through written and verbal means
Apply appropriate rules of grammar, usage, and style when preparing correspondence and documentation
Balance need for decisive, professional demeanor with warm, non‑confrontational customer‑first attitude; project empathy, confidence, and service‑oriented attitude
Organize and manage time to accurately complete tasks within designated time frames in a fast‑paced environment
Maintain confidentiality of patient and business information
Flexible: Ability to adjust work hours to meet business demands
Level Of Physical Demands
Sit and/or stand for prolonged periods of time
Bend, stoop, and stretch
Lift up to 20 pounds
Manual dexterity to operate computer, phone, and standard office machines
Equal Opportunity Employer / Veterans / Disabled
$22.61/hr – $27.14/hr
Summa Health offers a competitive and comprehensive benefits program to include medical, dental, vision, life, paid time off, and 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
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Full-Time / 40 Hours / Days
Hybrid after training
As a regional, provider‑owned health plan, SummaCare values the relationship between the members and their doctors. SummaCare is 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, family, and commercial insurance plans. SummaCare has one of the highest rated Medicare Advantage plans in 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.
Summary Reviews, processes, submits, and tracks all types of appeals and grievances, including expedited appeals. Communicates to departments responsible for implementing determinations.
Formal Education Required
High School Diploma or equivalent
Experience & Training Required
One (1) year of experience. Relevant experience includes: appeals/grievance experience in a managed care environment, or
Two (2) years performing claims processing, member services, or patient care experience in a healthcare environment
Essential Functions
Investigates, prepares and files all types of appeals and grievances, including expedited appeals, within designated timeframes
Investigates and researches member appeal/denial situations submitted in both phone interactions and written communications
May be required to participate in weekend on‑call rotation depending on assigned role (Commercial and Medicare Appeals Representatives)
Prepares post‑service, expedited appeal/grievance files for review by Medical Directors, Appeals Coordinator, or Appeals Committee
Writes appeals/grievance resolution letters to members, providers, and other appealing parties within defined time‑frames and format
Processes logs and files appeals and grievances in an organized and consistent manner
Communicates appeal/grievance decisions to departments responsible for implementing determinations, ensuring correct implementation
Communicates with members and providers while resolving appeals/grievances
Assists in tracking and trending appeal/grievance activity
Prepares documents for and records minutes of Appeals Committee meetings
Assists Appeals Coordinator as needed
May assist with the training of new staff and/or mentoring of new staff
Performs all job functions with integrity, providing timely internal and external customer service in a cooperative, professional, and respectful manner
Other Skills, Competencies and Qualifications
Demonstrate and maintain current understanding of various benefit packages, including intermediate knowledge of claims processes and systems
Demonstrate intermediate knowledge of Microsoft Office applications required to complete job functions (e.g., Word and Excel)
Demonstrate ability to practice knowledge of health insurance industry, including governing rules and regulations
Demonstrate ability to maintain current knowledge of and comply with regulatory and company policies and procedures
Demonstrate intermediate system knowledge; familiarity with telephone logs for research and logging purposes essential
Demonstrate ability to identify system coding problems on authorization and claim screens preventing payment of claims to direct problems to the correct department
Communicate and work effectively with others through written and verbal means
Apply appropriate rules of grammar, usage, and style when preparing correspondence and documentation
Balance need for decisive, professional demeanor with warm, non‑confrontational customer‑first attitude; project empathy, confidence, and service‑oriented attitude
Organize and manage time to accurately complete tasks within designated time frames in a fast‑paced environment
Maintain confidentiality of patient and business information
Flexible: Ability to adjust work hours to meet business demands
Level Of Physical Demands
Sit and/or stand for prolonged periods of time
Bend, stoop, and stretch
Lift up to 20 pounds
Manual dexterity to operate computer, phone, and standard office machines
Equal Opportunity Employer / Veterans / Disabled
$22.61/hr – $27.14/hr
Summa Health offers a competitive and comprehensive benefits program to include medical, dental, vision, life, paid time off, and 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
#J-18808-Ljbffr