Under the direction of the Manager of Long Term Care (LTC) Benefits, 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 adjudication of the claims. All work is directed under the terms and conditions of the various individual insurance contracts.
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 in conjunction with health care personnel at the physician office, hospital, home care agency, and/or nursing facilities and the Insured's family. 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 and audits the Insured's benefit file and claim payment to encourage timely submission of claims. Responsible for ensuring that all claims received are adjudicated within company and State time service standards. (this includes the task of claim payment)
Works closely with all providers and Insured's caregivers to conduct ongoing care conferences to determine continued need for services or level of care changes. Provides recommendations for changes in care settings or need for additional services and communicates coverage under the insurance contract.
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 - performs similar functions as Level 1 and can be differentiated as follows:
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.
Process Management and Documentation
Identifies, recommends and assesses new processes as necessary to improve productivity and gain efficiencies.
Assists in updated departmental policies, procedures and desk-top manuals relative to the functions
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.
Mentor (to others in department) - Provides guidance and leadership to the daily activities of the Department. Acts as resource to staff, members and providers.
Provides backup for the Manager, whenever necessary. Participates in the orientation of new staff and/training opportunities for all staff. Assists staff to identify opportunities to successfully manage claimants
Responsible for workflow coordination of the group.
Minimum Qualifications:
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:
RN or social worker with a minimum of three years combined experience in insurance and/or a clinical setting. Alternatively, Bachelor's degree with a minimum of five years combined experience in insurance and/or clinical setting, or Bachelor's degree with a minimum of two years' experience in long term care insurance claims processing.
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.
Strong 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 to detail.
A working knowledge of Microsoft Office applications is required. Skillful at working between multiple programs and applications at the same time.
Level II:
RN or Licensed Social Worker with a minimum of three years combined experience in insurance and/or clinical setting, or the candidate must have a minimum of two years combined experience in the Level 1 position.
Physical Requirements:
Pace is consistently fast, consistently variable tasks, very high level of interpersonal interaction, high problem-solving abilities, physical demands primarily sitting, talking, hearing, full use of visual fields and color discrimination, and fine finger motion.
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The Lifetime Healthcare Companies aims to attract the best talent from diverse socioeconomic, cultural and experiential backgrounds, to diversify our workforce and best reflect the communities we serve.
Our mission is to foster an environment where diversity and inclusion are explicitly recognized as fundamental parts of our organizational culture. We believe that diversity of thought and background drives innovation which enables us to provide leading-edge healthcare insurance and services. With that mission in mind, we recruit the best candidates from all communities, to diversify and strengthen our workforce.
OUR COMPANY CULTURE:
Employees are united by our Lifetime Way Values & Behaviors that include compassion, pride, excellence, innovation and having fun! We aim to be an employer of choice by valuing workforce diversity, innovative thinking, employee development, and by offering competitive compensation and benefits.
In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.
Equal Opportunity Employer
Compensation Range(s):
Level I: Grade 205: Minimum $56,347 - Maximum $81,702
Level II: Grade 206: Minimum $56,534 - Maximum $93,267
The salary range indicated in this posting represents the minimum and maximum of the salary range for this position. Actual salary will vary depending on factors including, but not limited to, budget available, prior experience, knowledge, skill and education as they relate to the position's minimum qualifications, in addition to internal equity. The posted salary range reflects just one component of our total rewards package. Other components of the total rewards package may include participation in group health and/or dental insurance, retirement plan, wellness program, paid time away from work, and paid holidays.
Please note: There may be opportunity for remote work within all jobs posted by the Excellus Talent Acquisition team. This decision is made on a case-by-case basis.
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.
