Long Term Services & Support Case Advisor

Responsibilities

• Represent the service coordination team as an employee voter on first-level appeals and as a witness for State Fair Hearings.
• Act as subject matter expert on LTSS for first-level appeals and State Fair Hearings.
• Research Participant cases to fully understand the PCSP, appeals, and grievance requests, including review of UM / claim denial reasons, contract / regulatory rules, benefits, and documentation received on appeal / grievance.
• Present testimony on behalf of the Plan in State Fair Hearings.
• Facilitate information gathering from participants / representatives during first-level appeals.
• Contribute to first-level appeal deliberations and decisions as part of the interdisciplinary team.
• Maintains familiarity and compliance with federal, state, and local regulations and other regulatory requirements (e.g., NCQA standards) relative to appeal and grievance operations and State Fair Hearings.
• Maintains quality and compliance standards as state and federal entities dictate.
• Maintains contractual agreements with participating providers related to appeals and grievances.
• Collaboration with internal counterparts to ensure proper appeal handling, e.g., LTSS UM team, medical directors, and service coordination.
• Maintains accurate, timely, complete records and documentation of appeals and state fair hearings, outcomes, follow-up, and resolution.
• Administrative tasks, including, but not limited to, letter processing, data collection, and assembling / filing completed appeals folders.
• Reviews and properly distributes incoming appeals / grievance information department-wide.
• Ensures timely communication between the LTSS Review UM Department, the Appeals Committee, and the Service Coordination Department through grievance and appeals processes.
• Follows up with the Service Coordination Department after a decision is rendered to ensure the appropriate care plan is in place.
• Ensures timely notification of appeals and grievances and responds accordingly.
• Ensures compliance with organizational and CHC guidelines.
• Identifies process bottlenecks and areas of needed education or improvement and suggests remediation.
• Other tasks as assigned.

Education / Experience :

Diversity, Equity, and Inclusion

At AmeriHealth Caritas, everyone can feel valued, supported, and comfortable to be themselves. Our commitment to equity means that all associates have a fair opportunity to achieve their full potential. We implement these principles daily by acting with integrity and respect. We stand together to speak out against injustice and to break down barriers to support a more inclusive and equitable workplace. Celebrating and embracing the diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve.

We keep our associates happy so they can focus on keeping our members healthy.

Our Comprehensive Benefits Package

Flexible work solutions include remote options, hybrid work schedules, competitive pay, paid time off, holidays and volunteer events, health insurance coverage for you and your dependents on Day 1, 401(k) tuition reimbursement, and more.

Generous paid time off and paid volunteer time off.

Employer-matched 401(k) and additional non-elective contributions, starting on day one.

Medical, dental, and vision plans — with coverage starting on day one.

Employee assistance programs, fitness reimbursements, nutrition counseling, and more.

Employer-paid life insurance, with opportunities to purchase additional coverage.

Employer-paid short-term disability coverage and long-term disability coverage.

Tuition assistance, including reduced tuition at certain schools.

Financial assistance with adoption, including paid time off.

Flexible spending and health savings accounts to pay for qualified expenses.

Discount programs on entertainment, travel, and more.