Claims Specialist

Claims Specialist

SummaCare - 1200 E Market St, Akron, OH

Full-Time / 40 Hours / Days

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 :
Assists claims management through providing support, training and education, to Claims processing staff, in a professional manner. Responsible for the accurate and timely handling of claims in accordance with regulatory and contractual guidelines. Reviews claims related to coordination of benefits, medical coding, authorization assignments, and necessary sub-system updates. Applies cost-containment techniques to minimize claim costs while ensuring adherence to plan-specific and line-of-business processing rules. Responsibilities include, but are not limited to, repricing reconciliation and case agreement claim processing. May assists Team Leads in the mentoring junior processors to support team development.

1. Formal Education Required :
a. High School Diploma or equivalent

2. Experience & Training Required :
a. Five (5) years' experience to include any combination of the following:
i. health insurance claims processing,
ii. health claims data entry including Document Management Services (DMS),
iii. customer service experience in a managed care environment,
iv. physician or hospital billing,
v. patient accounts

3. Other Skills, Competencies and Qualifications:
a. Word and Excel at an intermediate level and Access at basic. Must achieve passing score on test administered by Human Resources.
b. Skilled in medical terminology, CPT, HCPCs, and ICD-10
c. Understanding of professional (CMS1500) and institutional (UB-04) claim types
d. Health claims processing knowledge
e. Close attention to detail with independent judgment, decision making and problem solving skills
f. Strong analytical skills with the ability to interpret complex data sets and draw meaningful conclusions
g. Ability to effectively interact with populations of patients/customers with an understanding of their needs for self-respect and dignity

4. Level of Physical Demands:
a. Sit for prolonged periods of time
b. Bend, stop and stretch
c. Lift up to 20 pounds
d. Manual dexterity to operate computer, phone and standard office machines

Equal Opportunity Employer/Veterans/Disabled

$22.61/hr - $27.14/hr