Long Term Care Benefits Planner I/II (Rochester Region)

company•City of Rochester, NY

8d•$62,400 - $106,929•Onsite

About The Position

The Long Term Care Benefits Planner (Personal Care Advisor) evaluates and manages insureds who are accessing long-term care benefits. The role involves ongoing evaluation of benefit eligibility and plan-of-care appropriateness, coordination with other insurance policies and providers, documentation and communication with insureds, their families, and care providers, and monitoring claim submission and processing. All work is performed under the terms and conditions of the applicable individual insurance contracts. The position requires coming into the Rochester, New York office; remote work may be considered case by case. Level I independently manages a caseload, evaluates medical records and assessments to determine eligibility, assists with care planning and referrals, explains covered and noncovered services, evaluates claims against approved care plans, and supports timely claim submission and adjudication. Level II handles larger or more complex caseloads, mentors and trains less experienced planners, guides department activities, develops process improvements, and serves as a subject matter expert for escalations. The role requires professionalism, careful handling of confidential medical information, regular and reliable attendance, and the ability to travel across the Health Plan service region for meetings or training as needed. Flexible hours may be required to meet member discussion needs.

Requirements

Level I: Three years of combined experience in insurance and/or a clinical setting.
Level I: Active New York State RN license or a bachelor’s degree in social work or a related field.
Level I alternative qualification: Associate degree or LPN, plus at least two years of experience in long-term care claims adjudication and two years of long-term care customer service.
Ability to review and interpret medical records and assessments to determine benefit eligibility.
Basic analytical and problem-solving skills.
Ability to discuss confidential medical issues with customers.
High degree of professionalism and strong written and verbal communication skills.
Attention to detail.
Working knowledge of Microsoft Office applications and ability to work across multiple programs and applications at the same time.
Level II: Four years of combined experience in insurance and/or a clinical setting, or at least two years of combined experience in a Level I position.
Level II: Active New York State RN license, LMSW, or LCSW.
Level II: Ability to deliver efficient, effective, and seamless care to members.
Level II: Ability to escalate issues to management when necessary.
Level II: Proficiency in related technology and documentation requirements.
Ability to travel across the Health Plan service region for meetings and/or training as needed.

Nice To Haves

Experience in a long-term care setting or with geriatric populations.
Level II: Prior case management experience.

Responsibilities

Act as a case advisor, key contact, and advocate for insureds and their families as they access benefits under long-term care policies.
Independently manage an insured caseload in accordance with company time-service standards.
Review field assessments, medical records, and other information to evaluate insureds’ conditions and determine benefit eligibility under the policy contract.
Develop and assist with appropriate plans of care and refer insureds to external vendors to arrange care and manage private caregivers.
Explain which services are covered and not covered under the insurance contract and assist with arranging services when needed.
Evaluate submitted claims to determine whether billed and provided services are consistent with the approved plan of care.
Develop and document alternate plans of care when appropriate under the insurance contract.
Review benefit files and claim payments to encourage timely claim submission and adjudication within company and state time-service standards.
Maintain integrity and support the company’s mission and values while adhering to the Corporate Code of Conduct.
Protect member privacy in accordance with corporate privacy policies and procedures.
For Level II, manage larger or more complex caseloads while meeting time-service requirements.
For Level II, train and mentor less experienced LTC Benefits Planners, including helping interpret more difficult policy language.
For Level II, provide guidance and leadership regarding department daily activities and serve as a resource to staff, management, and vendors.
For Level II, identify and develop processes and guidelines to improve department performance.
For Level II, serve as a subject matter expert for escalations and work with operations to resolve issues and escalated problems.
Travel across the Health Plan service region for meetings and/or training as needed.
Perform other functions as assigned by management.