Long Term Care Planner I​/II; Rochester Region

Job Description

Summary: This position will require coming into the Rochester, NY Office.

The LTC Benefits Planner (Personal Care Advisor) has the responsibility of evaluating and managing those Insureds that are accessing their benefits based on their need for long-term care services. This includes ongoing evaluation of the Insured's eligibility for benefits, appropriateness of the plan of care, coordination of other insurance policies/providers, documentation and communication with Insured, Insured's family, care providers, and monitoring of claim submission and processing.

All work is directed under the terms and conditions of the various individual insurance contracts.

Level I

• Operates as a case advisor for Insureds accessing benefits under their LTC policy as key contact and advocate for Insured and their family. Independently manages a caseload of Insureds in accordance with time-service standards required by the Company.
• Evaluates Insured's condition through review of field assessments, medical records, etc. Determines benefit eligibility based on the criteria outlined in the LTC policy (contract).
• Develops and assists with appropriate plan of care for Insured. Provides referrals to external vendors to assist in putting care in place and managing private caregivers.
• Defines the services covered and not covered under the terms of the contract and assists with the arrangement of services as is deemed necessary.
• Evaluates submitted claims to determine if services billed and provided are consistent with the approved plan of care. Develops and documents alternate plans of care as deemed appropriate under the terms of the insurance contract.
• Reviews the Insured's benefit file and claim payment to encourage timely submission and adjudication of claims within company and State time service standards.
• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies' mission and values and adhering to the Corporate Code of Conduct.
• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
• Regular and reliable attendance is expected and required.
• Performs other functions as assigned by management.

Level II

• In addition to the essential accountabilities in Level I, manages a larger and/or more complex caseload of Insureds while maintaining time-service requirements.
• Trains and mentors less experienced LTC Benefit Planners including interpretation of more difficult policy language. Provides guidance and leadership regarding the daily activities of department. Acts a resource to staff, management and vendors.
• Identifies and develops processes and guidelines for performance improvement opportunities for the Department.
• Expert and resource for escalations - Serves as subject matter expert and if called upon, works directly with the operation to resolve issues and escalated problems.

NOTE:

We include multiple levels of classification differentiated by demonstrated knowledge, skills, and the ability to manage increasingly independent and/or complex assignments, broader responsibility, additional decision making, and in some cases, becoming a resource to others. In addition to using this differentiated approach to place new hires, it also provides guideposts for employee development and promotional opportunities.

Level I

• Three (3) years combined experience in insurance and/or a clinical setting.
• Active NYS RN License or bachelor's degree in social work or related field. In lieu of an RN or bachelor's degree, an associate's degree or LPN with a minimum of two (2) years' experience in long term care claims adjudication and two (2) years long term care customer service.
• Must have the ability to review and interpret medical records and assessments for the purpose of determining eligibility for benefits. Experience in long term care setting or with geriatric populations is preferred.
• Basic analytical and problem-solving skills.
• Ability to speak on confidential medical issues with customers.
• Must display a high degree of professionalism and have strong written and verbal communication skills.
• Attention…