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

Excellus BCBS•Rochester, MN

12d•$62,400 - $106,929•Onsite

About The Position

The Long Term Care Benefits Planner (Personal Care Advisor) evaluates and manages insured individuals who are accessing long-term care benefits. The role includes ongoing assessment of benefit eligibility and the appropriateness of care plans, coordination with other insurance policies and providers, documentation and communication with insured individuals, 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. Travel across the Health Plan service region may be needed for meetings or training, and flexible hours may be required to accommodate member discussions. At Level I, the planner independently manages a caseload, serves as a primary contact and advocate, reviews assessments and medical records to determine eligibility, helps develop appropriate care plans, explains covered and noncovered services, evaluates claims against approved plans, and promotes timely claim submission and adjudication. The planner also follows company standards and policies, including those related to integrity, privacy, and attendance. At Level II, the planner manages a larger or more complex caseload and also trains and mentors less experienced planners, provides guidance to staff and vendors, develops process improvements, and serves as a subject matter resource for escalations and difficult issues.

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: An associate's degree or LPN, plus at least two years of long-term care claims adjudication experience and two years of long-term care customer service experience.
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.
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 simultaneously.
Level II: Four years of combined experience in insurance and/or a clinical setting, or at least two years of combined experience in the 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 as 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

Serve as a case advisor, key contact, and advocate for insured individuals and their families accessing long-term care benefits.
Independently manage an insured caseload while meeting company time-service standards.
Review field assessments, medical records, and other information to evaluate an insured individual's condition and determine benefit eligibility under the policy.
Develop and assist with appropriate plans of care.
Refer insured individuals to external vendors and assist with arranging services and managing private caregivers.
Explain services covered and not covered under the insurance contract and assist with arranging necessary services.
Evaluate submitted claims to determine whether billed and provided services match 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.
Protect member privacy, follow corporate privacy policies and procedures, and support the company's mission, values, and Code of Conduct.
Maintain regular and reliable attendance and perform other functions assigned by management.
At Level II, manage a larger and/or more complex caseload while meeting time-service requirements.
At Level II, train and mentor less experienced planners, including on interpretation of complex policy language, and provide guidance to staff, management, and vendors.
At Level II, identify and develop processes and guidelines for department performance improvement.
At Level II, serve as a subject matter expert for escalations and work with operations to resolve issues and escalated problems.