Manager, LTSS Service Determination Operations

Job Summary:

The Manager, LTSS Service Determination Operations is responsible for leading the day-to-day operations of a market specific LTSS service determination function, ensuring accurate, timely, and compliant translation of assessments into appropriate long-term services and supports (LTSS), ensuring decisions are member-centered, operationally executable, and aligned with regulatory and cost-of-care objectives.

Essential Functions:

• Serve as the primary operational lead for LTSS service determinations within an assigned market(s), ensuring alignment with state‑specific program rules, waiver requirements, contractual obligations, and workflow nuances.
• Act as the key market‑level liaison for LTSS service determinations, partnering with local Care Management, Clinical, Product, and Compliance stakeholders to ensure operational readiness and issue resolution.
• Ensure timely and accurate determinations in alignment with medical necessity guidelines, benefit rules, and regulatory requirements.
• Drive consistency in service determinations across PCA, GAFC/AFC, Home Health, and Flexible Benefits.
• Serve as the primary operational owner of the service determination workflow (interim and future-state).
• Provide input into process design, rollout strategy, and system enhancements, ensuring operational feasibility and scalability.
• Identify gaps, inefficiencies, and variation in decision-making and implement standardized solutions.
• Lead continuous improvement initiatives focused on quality, turnaround time, and member experience.
• Develop and execute training and onboarding programs for new and existing staff.
• Ensure team readiness for new workflows, regulatory updates, and system changes.
• Partner with CM, Clinical and Compliance teams to ensure staff are trained on medical necessity guidelines and LTSS program distinctions.
• Directly manage and develop a team of service determination professionals.
• Provide coaching, mentorship, and performance management to drive high-quality outcomes.
• Monitor key performance indicators.
• Identify and mitigate risks related to service misalignment, duplication of services, and documentation gaps.
• Perform any other job related duties as requested.

Education and Experience:

• Bachelor's degree required
• Equivalent years of relevant work experience may be accepted in lieu of required education
• Three (3) years of experience in healthcare operations, with a strong focus on LTSS and Medicaid required
• Two (2) years of leadership experience managing teams in a healthcare or managed care environment required
• Three (3) years of experience supporting process redesign, transformation, or system implementation preferred
• Experience with assessment tools (MDS, functional assessments, health risk assessments) preferred

Competencies, Knowledge and Skills:

• Understanding of LTSS programs, including PCA (Personal Care Attendant), GAFC/AFC, Home Health Services, and Home and Community Based Services
• Proficient with Microsoft Office to include Word, Excel, and PowerPoint
• Excellent written and verbal communications skills
• Ability to develop, prioritize and accomplish goals
• Detail oriented
• Strong interpersonal skills and high level of professionalism
• Effective listening and critical thinking skills
• Effective problem-solving skills with attention to detail
• Ability to work independently and within a team
• Strong negotiation skills
• Excellent leadership skills
• Ability to create and maintain excellent working relationships

Licensure and Certification:

• None

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time
• Travel is not typically required

Compensation Range:

$83,000.00 - $132,800.00

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Salary

Organization Level Competencies

• Fostering a Collaborative Workplace Culture

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

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